Konstantinos Kollios

Duplex Collecting System Diagnosed During the First 6 Years of Life After a First Urinary Tract Infection: A Study of 63 Children

PURPOSE We determined the prevalence, anatomical variants and coexisting complications of duplex collecting systems in children with a history of UTI. Additionally, we compared the prevalence and severity of the coexisting anomalies with those found in single systems. MATERIALS AND METHODS We reviewed the records of children younger than 6 years who were evaluated following a first UTI during a 9-year period to identify those with duplex systems. Children without duplication anomalies comprised the control group. RESULTS Of 774 evaluated children 63 (8%), more commonly females than males, had duplex systems. CDS were as common as IDS. VUR was the most commonly associated anomaly, with a higher prevalence in CDS (66%) and IDS (47%) compared to single systems (26%, p <0.0001 and p = 0.007, respectively). Ectopic ureterocele, which was the second most common associated anomaly, was found in 20% of the CDS but in none of the IDS or single systems. The occurrence of renal scarring was similar among CDS, IDS (13%) and single systems (10%). Poorly functioning pole moieties occurred more often in CDS (40%) compared to IDS (4%, p = 0.003), and were observed in none of the single systems. The resolution rate of reflux tended to be higher in IDS compared to CDS. CONCLUSIONS CDS were a common finding among children with UTI who had duplication anomalies. Although CDS and IDS were accompanied by VUR more often than were single systems, CDS were associated more often with severe VUR, other serious complications and poor renal function.

Bilirubin levels predict renal cortical changes in jaundiced neonates with urinary tract infection

BackgroundThis study was undertaken to determine the incidence of urinary tract infection (UTI) and the frequency of anatomical abnormalities in newborns with unexplained jaundice and to find out if there is any correlation between bilirubin level and renal damage.MethodsWe studied 462 full-term neonates for UTI. They were aged 3–25 days, with either high (>10 mg/dL) or prolonged (>10 days) hyperbilirubinemia, with or without manifestations such as fever, vomiting, diarrhea, poor feeding, lethargy, and irritability. Neonates positive for UTI were further investigated with ultrasound, cystourethrography, and acute phase renal scintigraphy with technetium-99m dimercaptosuccinate acid (DMSA).ResultsThirty neonates (6.5%) were found to have UTI. Twenty-eight of them had indirect hyperbilirubinemia and two had direct hyperbilirubinemia, with total bilirubin levels of 11.8–20.1 mg/dL. None of the neonates was found to have jaundice because of other reasons such as infection. Vesicoureteral reflux was found in 5 neonates and one of them was combined with hydronephrosis. Renal scintigraphy with technetium-99m DMSA showed renal cortex changes in 14 (46.7%) of the 30 neonates with UTI. These 14 neonates also had increased levels of bilirubin in comparison to those with normal findings of DMSA.ConclusionsThe incidence of UTI in uncomplicated neonatal jaundice is relatively high. Anatomical abnormalities of the urinary tract are not rare in infected children. Increased bilirubin levels are related to pathological findings in renal scintigraphy.

Primary Intestinal Lymphangiectasia: Is It Always Bad? Two Cases with Different Outcome

Primary intestinal lymphangiectasia (PIL) or Waldmanns disease is a rare protein-losing gastroenteropathy of unknown etiology. Less than 200 cases have been reported globally. Patients may be asymptomatic or present edema, lymphedema, diarrhea, ascites and other manifestations. We report two pediatric cases with PIL with extremely different outcome in a 3-year follow-up period. The first patient presented with persistent diarrhea, hypoalbuminemia and failure to thrive, while the second patient presented with an abrupt eyelid edema. Hypoproteinemia was the common laboratory finding for the two patients and upper gastrointestinal endoscopy established the diagnosis. The first patient relapsed five times during the follow-up period after the diagnosis had been made and required intravenous albumin administration and micronutrient supplementation. The second patient revealed normal gastrointestinal endoscopy 4 months after the diagnosis had been established; he followed an unrestricted diet and remained asymptomatic throughout the follow-up period. PIL can be either severe, affecting the entire small bowel, leading to lifetime disease, or sometimes affects part of the small bowel, leading to transient disorder.

Acute phase 99mTc-dimercaptosuccinic acid scan in infants with first episode of febrile urinary tract infection

Background99mTc-dimercaptosuccinic acid (DMSA) scan is the golden standard for the diagnosis of acute pyelonephritis and renal scaring. We investigated the use of acute phase DMSA scan in infants presented promptly to the hospital because of the first episode of their febrile urinary tract infection (UTI).MethodsNinety-eight infants with microbiologically confirmed first episode of febrile UTI were studied. DMSA scans were carried out within 7 days in these infants after admission. Infants with an abnormal acute DMSA scan underwent a second DMSA scan 6–12 months later.ResultsOverall, acute DMSA scan was abnormal in 16 (16.3%) of the 98 patients. There were no differences in sex, age, fever over 38.5°C, blood inflammation indices, or evidence of vesicoureteral reflux (VUR) between patients with normal and abnormal acute DMSA scan (P>0.05). However, infants with grade III to V VUR as well as those with delayed treatment presented significantly increased renal involvement by acute DMSA scan (P<0.05). The sensitivity and specificity of abnormal acute DMSA scan to predict grade III to V VUR were 50% and 88% respectively. Its positive and negative likelihood ratios were 4.16 and 0.57, respectively. Of 16 children with abnormal initial DMSA scan results, 14 underwent a second DMSA scan. Follow-up DMSA scans were normal in 12 of the 14 children.ConclusionsParenchymal damage found in a minority of infants with febrile UTI presented promptly to the hospital. Acute phase DMSA scan should be carried out only in selected patients. An abnormal acute DMSA scan is a moderate predictor for dilated VUR and its ability to exclude VUR is restricted.

Long-Term Changes in Blood Pressure After Pediatric Kidney Transplantation

BACKGROUND Hypertension presents high prevalence rates following kidney transplantation (Tx). The aims of the present study were to investigate the prevalence and possible risk factors for hypertension and blood pressure (BP) control over time after pediatric kidney Tx, as well as to assess possible effects of hypertension on graft survival. METHODS We reviewed the medical records of all pediatric kidney recipients followed up in our pediatric nephrology department. Hypertension was defined as systolic and/or diastolic BP greater than the 95th percentile for age and sex, or as being on antihypertensive medication. BP control was defined as normotension while on antihypertensive medication. RESULTS The study population included 74 pediatric kidney recipients (median age 11 years). The prevalence of hypertension was found 77% before Tx, 82.4%, 71.7%, and 61% at 1, 5, and 10 years after Tx, respectively. Deceased donor Tx and pre-transplant hypertension on antihypertensive medication were significant risk factors for hypertension after kidney Tx over the follow-up period. BP control among patients on antihypertensive treatment was 16.7% before Tx, 43.8%, 66.7%, and 42.9% at 1, 5, and 10 years post-Tx, respectively. Hypertensive patients at 10 years post-Tx had 8.079 times higher hazard of graft loss compared to normotensives (95% CI 1.561-41.807, P < 0.05). CONCLUSIONS Hypertension remains a frequent complication in pediatric kidney recipients even years after kidney Tx. BP control by antihypertensive treatment is unsatisfactory in about half of the patients. The adverse effects of hypertension on graft survival may appear in the long-term.

Long-term outcome of pediatric kidney transplantation: A single-center experience from Greece

Pediatric kidney Tx has critically altered the outcome in ESRD pediatric patients. The aims of this study were to determine long‐term graft and patient survival in a homogeneous ethnic population. We reviewed the medical charts of pediatric kidney Tx performed between 1990 and 2012 in Greece. Seventy‐five kidney Txs were performed from LRD and 62 from DD. The 10‐ and 20‐yr graft survival was higher in LRD Tx compared with DD Tx. Both patient and graft survival at 10 and 20 yr after Tx were similar in LRD Tx from grandparents compared with parents (92.9% vs. 93.4% 20‐yr patient survival, 71.4% vs. 78.7% and 57.1% vs. 72.1%, 10‐ and 20‐yr graft survival, respectively). However, there was a decreasing tendency in LRD Tx rates in period 2001–2012 compared with period 1990–2000 (47.1% vs. 62.7%). Risk factors for poor five‐yr graft survival were DD Tx, and induction treatment with ALG compared with basiliximab, but their effect attenuated at 10 yr after Tx. In conclusion, Tx from LRD may offer efficient survival outcomes irrespective of donor age, suggesting that even older LRD could be an excellent option for the 1st kidney Tx in children and adolescents.

Antibiotics-Induced Acute Interstitial Nephritis in 6 Children

Introduction: Antibiotics-induced acute interstitial nephritis (AIN) is a rare disorder in children, and the diagnosis is often delayed. However, many commonly prescribed antibiotics seem to be implicated. Patients and Methods: We reviewed the medical records of 6 children, age range from 10 months to 14 years, with biopsy-confirmed antibiotics-induced AIN. Clinical presentation, morphological findings, and outcomes are reported. Results: Symptoms of AIN started 2–4 weeks after antimicrobial therapy with β-lactam antibiotics in 5 children and with gentamicin in 1 child. All patients presented with acute renal failure and fever. The glomerular filtration rate was dramatically reduced in 2 cases and mildly reduced in 4 patients. Two of our patients had supportive treatment, 2 received corticosteroid therapy, and 2 children remained under peritoneal dialysis for 12 and 22 days, respectively. Five patients had a full recovery of their renal function, and 1 child, 2 years later, still presented impairment of the renal function. Conclusion: AIN should be considered in case of acute renal failure in children, mostly when other common causes have been excluded, and there is a history of drug exposure.

Angiotensin II type 2 receptor gene polymorphism in caucasian children with a wide spectrum of congenital anomalies of the kidney and urinary tract

The A-1332G transition of the angiotensin II type 2 receptor (AT2R) gene was found to occur more often in males with ureteropelvic (UPJO) or ureterovesical junction obstruction (UVJO). However, other studies have shown controversial results. Τhe frequency of this polymorphism was investigated in 275 Caucasian children (153 boys, 122 girls) with a wide spectrum of congenital anomalies both of upper (165) and lower (110) urinary tract system and in 200 controls (100 boys, 100 girls). Among the included malformations, renal agenesis and duplex collecting system (DCS) were studied for the first time. The frequency of the G allele did not differ among patients (193 of 397 total alleles, 48.6%) and controls (146 of 300, 48.7%). No significant difference was also found in the frequency of the G allele in subgroups of congenital uropathies compared with controls. When analysis was performed in males and females separately, no significant difference was found in the frequency of the G allele in male (45.1%) or female (50.8%) patients compared with male (57.0%) or female (44.5%) controls. Our data indicate that the AT2R gene A-1332G transition is not associated with the development of human congenital uropathies and further investigations should be carried out to unravel their etiology.

PREVALENCE OF BP ELEVATION IN A SCHOOL-BASED POPULATION SCREENING: THE KASTORIA STUDY

Objective: We assessed the prevalence of high blood pressure (BP) in a school based screening study according to the ESH 2016 guideline diagnostic thresholds. Moreover, risk factors for BP elevation in childhood and adolescence, as well as geographic and seasonal risk factors, were investigated for their effect on BP population screening. Design and method: We performed a school-based BP screening study in the municipality of Kastoria in north Greece an area with 50,322 inhabitants. All schools in the municipality were visited during 2013–2016. A trained physician measure BP thrice by a mercury sphygmomanometer according to ESH 2016 guidelines and the last two BPs of this single occasion were averaged for the analysis. Personal history was recorded. Anthropometric measurements were obtained and obesity was defined according to IOFT criteria. Results: 2,832 children and adolescents aged 6–18 years participated in the study. The prevalence of high-normal BP and hypertension in the population was 3.7% and 0.9%, respectively, according to ESH 2016 BP classification. Thirty one % of the population was overweight (22.9%) or obese (9.5%). Among participants with BP elevation, 56.1% of the participants presenting high-normal BP, 55.5% hypertensive and 66.7% isolated systolic hypertensive BP levels were overweight or obese. High BP levels prevalence did not differ by sex, birth weight or gestation week. Prevalence rates were similar in city and surrounding rural areas. Higher prevalence of high normal or hypertensive BP levels was observed during the spring (57.1%) and winter (23.3%) period compared to about 10% at autumn and summer (P < 0.05). Both the highest prevalence of overweight/obesity and elevated BP levels were found in the 6–12 years-old group (62% vs. 38%, P < 0.001 for overweight-obesity, and 27.1% vs. 78.9%, P = 0.05 for high-normal/hypertensive BP levels). The highest prevalence of hypertensive BP levels (27.8%) was observed at 6th grade children. Conclusions: In this European population a low rate of high-normal and hypertensive BP levels was found in single visit following the ESH 2016 guidelines protocol for BP measurement. Overweight and obesity was associated with higher BP levels, but there were also seasonal differences in the prevalence of high BP levels.

PERFORMANCE OF THE AAP 2017 GUIDELINE SIMPLE TABLE ON BP SCHOOL-BASED SCREENING IN A EUROPEAN POPULATION

Objective: We assessed the performance on BP population screening of the simplified AAP 2017 clinical practice guideline based on age and 5th percentile of height, and a similar simplified table based on the 4th Report BP reference tables compared to the ESH 2016 guideline diagnostic thresholds. Design and method: We obtained data from a school-based screening study for the prevalence of high BP in the municipality of Kastoria in north Greece. Blood pressure was measured thrice by a mercury sphygmomanometer according to ESH 2016 guidelines and the last two BPs were averaged for the analysis. Results: The study population included 1,846 children aged 6–12 years and 986 adolescents aged 13–18 years. Compared to the ESH 2016 classification, the AAP 2017 table showed AUC 0.936, sensitivity 95.5%, specificity 91.6%, NPV 99.8%, and PPV 36%, while the 4th report table showed AUC 0.963, sensitivity 99.2%, specificity 93.3%, NPV 100%, and PPV 42.2%. The performance of the 4th report table was similar in both age groups, while the performance of the AAP 2017 table was lower in the adolescent group (AUC 0.884, sensitivity 83.2%, specificity 93.5%, NPV 99.3%, and PPV 32.6%, in adolescents versus AUC 0.953, sensitivity 100%, specificity 90.6%, NPV 100%, and PPV 37.2% in 6–12 years-olds, P < 0.05 for difference in AUC between age groups). Comparing the prevalence of elevated BP by the two simple tables we found agreement by both tables in 96.9% of the subjects (86.7% had normotension and 10.2% had high-normal or hypertensive BP levels), and disagreement in 3.1%. All children classified for further screening by AAP 2017 table were normotensive by ESH 2016 classification. However, 20,8% of the adolescents classified for further screening by 4th report, but not by AAP 2017 table, had BP levels at the high-normal category according to ESH 2016 classification. Conclusions: Simple tables for BP screening based on age present good performance to identify children and adolescents with normal BP levels. However, the table by AAP 2017 guideline may provide high rate of false positive results and fail to classify adolescents eligible for further BP measurements and lifestyle modification.