M. Ashraf

Prevalence and spectrum of congenital heart diseases in children

Background: Congenital heart disease (CHD) is one of the major causes of mortality and morbidity in the pediatric population of both the developing and developed countries. Variability in incidence and prevalence of CHD from various countries of Indian subcontinent and rest of the world could be because of genetic, cultural, and environmental factors. Objective: To find the prevalence and pattern of CHD in a tertiary care hospital in Kashmir (J&K). Materials and Methods: A retrospective analysis of case-records data of 767,921 patients (0-18 years) over 3 years and 10 months period was conducted to ascertain the prevalence and spectrum of CHDs. Results: A total of 877 patients out of 767,921, were found having CHDs measuring a prevalence of 1.12/1000. About 777 (88.5%) were the acyanotics, and 100 (11.5%) were cyanotic heart patients. Among the acyanotic heart diseases ventricular septal defect was the most frequent lesion seen in 241 (31.2%), followed by patent ductus arteriosus in 184 (24.3%) children. Among the cyanotic heart diseases tetralogy of Fallot was the most frequent cyanotic heart disease seen in 48 (48.0%) patients. Conclusion: Prevalence of 1.12/1000 among the hospital attending patients could be an underestimation of the actual disease burden in our community, and heightened awareness among the treating physicians about the cardiac diseases could actually reduce the mortality and morbidity associated with these ailments.

Pediatric acute kidney injury: A syndrome under paradigm shift

The recent standardization and validation of definitions of pediatric acute kidney injury (pAKI) has ignited new dimensions of pAKI epidemiology and its risk factors. pAKI causes increased morbidity and mortality in critically ill-children. Among the hospitalized patients incidence of pAKI ranges from 1% to 31%, while mortality ranges from 28% to 82%, presenting a broad range due to lack of uniformly acceptable pAKI definition. In addition, cumulative data regarding the progression of pAKI to chronic kidney disease in children is rising. Despite these alarming figures, treatment modalities have failed to deliver significantly. In this review, we will summarize the latest developments of pAKI and highlight important aspects of pAKI management.

Incidence of pediatric acute kidney injury in hospitalized patients.

Pediatric acute kidney injury (pAKI) is a common complication associated with high mortality in children. The objective of this study was to determine the incidence of acute kidney injury (AKI) and mortality in hospitalized (critically ill and non-critically ill) patients. This was a retrospective study conducted during the period of June 1, 2013, to May 31, 2014, at the Postgraduate Department of Pediatrics, G. B. Pant Hospital, an Associated Hospital of Government Medical College, Srinagar, Jammu and Kashmir, India. All patients between the ages of one month and 18 years were included in the study, who had AKI. In general, out of 23,794 patients, 197 developed AKI (0.8%). On subgroup analysis, 2460 were critically ill and had Intensive Care Unit (ICU) admission among whom 99 developed AKI (4%), whereas 21,334 had general pediatric ward admissions and 98 developed AKI (0.5%). Infantile age group was the most commonly 91 (46.2%) affected. The common causes of AKI were renal in 73 (37%), neurologic in 38 (19%), septicemia in 35 (18%), and inborn errors of metabolism in 30 (15.2%). Out of 197 pAKI patients, 42 (21.3%) died and all of them were critically sick (ICU admissions). The incidence of pAKI in general was 0.8%, whereas it was 4% in critically ill children and 0.5% in general ward admissions implying an eight-fold increased risk of pAKI in critically ill patients.

Moyamoya disease masquerading as recurrent headaches in a 4-year-old child

Moyamoya disease can have varied clinical manifestations and the diagnosis is often made only on acute presentation. We present a case of 4 year old male child diagnosed with moyamoya disease who had a history of recurrent headaches in past.

Unilateral Renal Tuberculosis Presenting as Persistent Pyuria

Introduction: To determine whether the timing of voiding cystoureterogram (VCUG) in the first or the third week after a diagnosis of urinary tract infection (UTI) is important in the diagnosis and severity of VUR. Materials and Methods : In this case-control study, 72 children between 1 month and 15 years old diagnosed with their first episode of UTI were investigated over one year. The study population was divided into 2 groups of 36, early (VCUG in the first week after UTI) and late (VCUG 3 weeks after UTI), and compared the severity and incidence of reflux in both groups. Results: The prevalence of VUR was 66.6%. Twenty-two cases in the first group (61%) and 26 cases in the second group (72.2%) presented with VUR. The peak age of the disease in both groups was 1-3 years with a female predominance. The most common germ detected was E-Coli and the most common presentations were fever (87.5%) and dysuria (26.3%). Conclusions: As VUR following UTI is very common in children and is one of the most important risk factors of early hypertension and chronic renal failure, early diagnosis by VCUG seems to be useful in all UTI patients before discharge. Keywords: Urinary Tract Infection; Vesico-Ureteral Reflux; VCUG; Child.Introduction: Urinary tract infection is one of the common bacterial infections seen in infants and children. As children present with non-specific symptoms, a diagnosis of UTI is often missed or it is diagnosed very late. A wide range of organisms with varying antibiotic sensitivity patterns have been known to cause UTI. The objectives of the study were: To study the clinical profile of children with UTI To study the microbiological profile of children with UTI To study the antibiotic resistance profile of various organisms causing urinary tract infection in children. Materials and Methods : A retrospective Study was conducted in the Department of Pediatrics, CHRI, for 2 years from Jan 2014 to December 2016. The data of the children who met the inclusion criteria were collected from the case records. The collected data was tabulated and analyzed using IBM SPSS version 21. Results: Males comprised a higher proportion of subjects in <1 year and 1-5 years when compared to females. Fever was the most common presenting symptom in the study population, which was seen in 220 (80.8%) children. The number of children with a positive culture for E.coli was 154 (56.0%) and Klebsiella was isolated in 37 (13.45%) children. A high proportion of E coli and Klebsiella species showed resistance to beta lactams and fluoroquinolones. E.coli was the most common organism in all age groups. The proportion of females was higher in the E. coli group (58.9%). Klebsiella had the highest proportion of resistance to more than 2 drugs (82.4%). Conclusions: The most common age group affected by urinary tract infection is below 1 year with a male preponderance followed by above 5 years with a female preponderance. The most common isolated organism in all age groups was E. coli, which was found to be resistant to beta lactams and fluoroquinolones. Therefore, in any child with suspected, it is advised to start empirical therapy with an antibiotic, like amikacin and nitrofurantoin, and wait for the results of urine culture and sensitivity testing. Keywords : Urinary Tract Infections; Child; Clinical; Microbiological.Introduction: Urinary tract infection is a common health problem in children . Gram negative entericbacteria, mainly E –coli, are responsible uropathogens. We aimed to define the main etiologies of urinary tract infection in children considering gender and type of infection (febrile versus afebrile). Materials and Methods : We assessed the infections etiology of 648 episodes. Type of infection and etiology were compared between genders. Also, for every uropathogen, a comparison was done between febrile and afebrile infections. Chi square was used for data analysis and P values ≤0.05 were considered as a significant difference. Results: The majority of the infections by Proteus and Enterococcus species were febrile, in contrast to Citrobacter infections which were mostly afebrile. E-coli infections were significantly more prevalent in girls (P=0.0001 ) . Proteus and Kelebsiella infections were more common in boys (P=0.115 and 0.154 respectively), whereas all Enterobacter infections were seen in girls (P=0.129). A comparison was done between females and males based on the type of infection. Although febrile infections were more frequent in boys, the difference was not statistically significant (P=0.059). Conclusions: E-coli, Kelebsiella, Enterobacter and Citrobacter species (90.5%) were the main uropathogens. Infections caused by E-coli were significantly more prevalent in girls. Proteus and Kelebsiella infections were more common in boys, whereas Enterobacter species were more prevalent in girls. The majority of Proteus and Enterococcus infections (>2/3) presented as pyelonephritis, while the frequency of febrile and afebrile infections was similar for E-coli, Kelebsiella, Enterobacter and Staphylococcus species. Keywords : UTIs; Etiology; Gender; Pyelonephritis; Cystitis.Williams-Beuren syndrome is a rare neurodevelopmental disease, in which mental retardation is common with this submicroscopic chromosomal deletion genetically disease. We reported a boy with Williams-Beuren syndrome and highlighted the clinical characteristics and response to treatment with Ritaline of such an individual with ADHD and voiding dysfunction. The patient was a six year-old boy with typical presentation of WBS and some psychiatric problems referred because of hyperactivity symptom and attention deficit. Children with mental retardation and WBS have a comorbidity of psychiatric disorders and kidney anomalies. Williams-Beuren syndrome can present with hyperactivity and Ritalin can improve some symptoms and voiding dysfunction. Keywords: Williams-Beuren Syndrome; Attention Deficit Disorder with Hyperactivity; Ritalin ; Methylphenidate.Introduction: The modified Asopas procedure for repair of hypospadias is well established and suited for patient characteristics for which Snodgrass urethroplasty cannot be done. We describe our experience with this procedure in 30 patients managed with this procedure highlighting the factors affecting outcome in this repair. Materials and Methods: Data of 30 patients (age range 2.5-15 years) who underwent hypospadias repair in a tertiary care teaching institution from 2012 to 2015 with modified Asopa procedure (Hodgson XX technique) utilizing Transverse Preputial Island Flap by a single surgeon were reviewed and retrospectively analyzed according to age of patients, site of meatus, presence or absence or chordee, glans configuration and complications - fistula, glans dehiscence, meatal stenosis. These complications were further analyzed with respect to the various patient characteristics and GMS (Glans, Meatus and Shaft) score. Results: The mean age of presentation was 5.5 years and mean follow-up period was 22 months. The mean total GMS score was 8.5; range being 11 to 5. In total, only six patients had complications (20%). The patients with low GMS score (7 or less) had no complications. The complication rate was more in proximal hypospadias repair (n= 5/24) when compared with distal hypospadias (n=1/6). There were more complications in patients with chordee (n=4/6) and those with conical glans (n=4/6). Conclusion: Location of the meatus, presence/absence of chordee and glans configuration affect outcome in patients undergoing modified Asopas procedure for hypospadias repair. Keywords: hypospadias; Asopas procedure; Child; Complications; Outcome .A 13-year-old boy was admitted in emergency room with sever generalized edema, hypertension and gross hematuria. He just had a positive history of upper respiratory tract infection 2 weeks ago. His laboratory tests revealed glomerular hematuria, nephrotic range proteinuria, low complement levels (both C3 and C4 levels) and normal renal function. Supportive therapy was started for him but after 4 weeks, clinical symptoms were not resolved and complement levels remained in low levels of normal. Kidney biopsy was performed and findings are compatible with c3 glomerulopathy with membranoproliferative histologic pattern (figure 1). His symptoms were resistant to prednisolone and cyclosporine therapy, and two months later he showed pluresia and non-infected skin lesions in both legs.A 3.5year old boy presented with failure to thrive. He had a history of congenital hypothyroidism that was under therapy with levothyroxine. There was absent metacarpal of left thumb that was reconstructed by Oscuneiform bone graft (Fig.1) A café-au-lait spot was detect on suprapubic region. The initial lab test revealed mild thrombocytopenia. eGFR was 75 ml/min/1.73m2 . Renal ultrasound showed that both kidneys were smaller than normal for age with mild hydronephrosis in left pelvic kidney. Tc 99m -DMSA renal scintigraphy con irmed left ectopic kidney (Fig.2)Introduction: Urinary tract infection (UTI) is a common pediatric problem. It has been estimated that 8% of girls and 2% of boys suffer from UTI during childhood. So, prevention of scar formation in high risk children is very important. This study was performed to evaluate the causes of recurrent urinary tract infection in children on prophylaxis. Materials & Methods: This study was performed on 141 cases in 126 children with recurrent UTI. A questionnaire was prepared and data including sex, age, grade of vesicoureteral reflux, and antibiotic used for prophylaxis were collected. Results: The mean age of the patients was 46.6±41.1 months; 24 % of the participants were male and 76% were female. The most common predisposing factor of recurrent UTI was vesicoureteral reflux. E.coli was the microorganism responsible for most of the cases (85.5%). In 85.5% of the children, Co-trimoxazole was used as prophylaxis. Drug resistance was the most common reason of recurrence. Conclusions: We conclude that girls are at higher risk of recurrent infection and regarding the high prevalence of Co-trimoxazole resistance, administration of this drug should be limited and with caution. Keywords: Urinary tract infections; Vesico-Ureteral Reflux; Drug resistance; ChildStreptococcal pharyngitis is common in the pediatric age group. Although its treatment is simply achieved by administration of a single dose of benzathine penicillin, oral penicillin for 10 days, or azithromycin for 5 days, it has serious complications such as rheumatic fever (RF) and chorea if left untreated. Treatment of pharyngitis does not prevent glomerulonephritis but prevents the spread of streptococci that can cause an epidemic in glomerulonephritis if they are of the nephritogenic strain. Post Streptococcal Glomerulonephritis (PSGN) is common in school age children and usually has a benign course as more than 95 percent of the cases recover the acute phase and less than 5 percent progress in their course to Rapidly Progressive Glomerulonephritis (RPGN) and ultimately about one percent develop End Stage Renal Failure (ESRF). Herein, we present a 12-year-old male with a history of untreated streptococcal pharyngitis who first came to our clinic with a history of arthralgia and arthritis, fatigue, hematuria, petechia, purpura, elevated levels of Blood Urea Nitrogen (BUN) and Creatinine (Cr), and low grade fever. Echocardiography revealed endocarditis which was treated. However, renal failure required renal replacement therapy (RRT), and massive proteinuria needed renal biopsy which revealed membrano proliferative glomerulonephritis (MPGN). Keywords: Streptococcal Infections; Membranoproliferative; Glomerulonephritis; Pharyngitis; Renal failure.EMOTIONAL DISORDERS IN CHILDREN WITH MONOSYMPTOMATIC PRIMARY NOCTURNAL ENURESIS Parsa Yousefichaijan--- , Bahman Salehi--- , Mohammad Rafiei--- ,Niloofar Ghadimi--- , Hassan Taherahmadi--- , Seyed Mojtaba Hashemi--- , Mahdyieh Naziri--- ABSTRACT Introduction: All children sometimes misbehave and some may have temporary behavioral problems due to stress. For example, the birth of a sibling, a divorce, or a death in the family may cause a child to act out. Behavior disorders are more serious. They involve a pattern of hostile, aggressive, or disruptive behaviors for more than 6 months. The behavior is also not appropriate for the childs age. Nocturnal enuresis (NE) is one of the most frequent pediatric pathologies. The prevalence of primary nocturnal enuresis (PNE) is around 9% in children aged 5-10 years and about 40% of them have one or more episodes per week. Materials and Methods: in this study, we recruited 146 children with MPNE and 146 healthy children without MPNE aged 6-18 years old. The children behavioral checklist for children behavioral assessment was completed by the parents. Data was analyzed using ANOVA and chi- square tests. Results: Among 292 children in both groups, somatic complaints, thought problems, delinquent problems, social problems, and ADHD were not significantly different between cases and controls while internalization, externalization, anxiety-depression, aggressive behaviors, isolation-depression, and affective-behavioral problems were significantly different. Conclusions: Considering the results of this study, the higher prevalence of behavioral problems in children with MPNE highlights the importance of early intervention for better treatment and prevention of behavioral problem in children. Keywords: Emotional Disturbances; Nocturnal Enuresis; Child.March 12, 2015 will mark the 10th anniversary of World Kidney Day (WKD), an initiative of the International Society of Nephrology and the International Federation of Kidney Foundations. Since its inception in 2006, WKD has become the most successful effort ever mounted to raise awareness among decision-makers and the general public about the importance of kidney disease. Each year WKD reminds us that kidney disease is common, harmful and treatable. The focus of WKD 2015 is on CKD in Disadvantaged Populations. This article reviews the key links between poverty and CKD and the consequent implications for the prevention of kidney disease and the care of kidney patients in these populations.. Aphallia (total absence of penis) is an extremely rare abnormality that can be part of the urorectal septum malformation sequence. We are reporting a 40-day-old boy who was referred to our nephrology clinic due to the absence of the penis and urinating through the rectum. He was born to a 17-year-old mother and a 24-year-old father, and was delivered term via normal vaginal delivery. The pregnancy was uncomplicated with no maternal toxin or medication exposure. Both parents were healthy and there was no family history of congenital abnormality. The parents were also unrelated. Physical examination revealed agenesis of the penis, a normal scrotum, and bilateral normally positioned testises. Moreover, the heart, lungs, abdomen, head and neck, and spinal column were all normal on examination. The karyotype was 46XY and the gender was male. Initial ultrasonography one week after birth revealed moderate bilateral hydronephrosis but the last ultrasonography 45 days later revealed only mild fullness of both kidneys. Keywords: Aphallia; Gender; penile agenesis.We report a case with Wilson’s disease who developed nephrotic syndrome one year after starting D-pencillamine. After stopping D-penicillamine, only zinc was given for maintenance. His proteinuria resolved after four weeks of full dose prednisolone administration and three intravenous methylprednosolone injections for nephrotic syndrome. Membranous glomerulopathy is most commonly associated with nephrotic syndrome secondary to D penicillamine but isolated cases of minimal change lesions are also reported like our case. The most likely cause of nephrotic syndrome in this child was the late complications of D-penicillamine. It also reemphasizes the importance of early monitoring for proteinuria and the need to shift to an alternative agent if side effects develop. Keywords: Nephrotic syndrome; D-pencillamine; Wilson’s disease.Ischemia reperfusion damage usually occurs after renal transplantation. These injuries can stimulate the innate immune system, trigger an inflammatory response and ultimately activate the adaptive immune system. These events may result in rejection, graft fibrosis and chronic allograft nephropathy. Different mechanisms contribute to innate immune system activation following ischemia reperfusion injury in renal transplants. Some of these mechanisms are known and described by investigators while the remainin g are still unknown. To clarify the precise mechanisms underlying the innate immune system activation and rejection progression helps us to plan therapeutic protocols to reduce immunologic responses to ischemic events and to improve the graft function andoutcome. In this review, we will discuss how innate and adaptive immune systems are activated during an ischemic insult and thereafter discuss related therapeutic interventions to block the activating pathways.A 3-year old boy with fever (40°), chill, malaise, nausea and vomiting from 5 days ago came to pediatric clinic. He had no positive past medical history. His lab data revealed marked leukocytosis with ESR:115 and CRP:102. His urine analysis was in favor of urinary tract infection and urine culture was positive. Because of sonography report, spiral CT scan with contrast was done. What is your diagnosis?Introduction: Steroid resistant nephrotic syndrome due to idiopathic focal segmental glomerulosclerosis (FSGS) or genetic mutations is one of the most common causes of end-stage renal disease (ESRD) that leads to renal transplantation. The relapse of the disease in the transplanted kidney, despite proper therapeutic management pre and post transplantation, may result in graft loss. Lack of accurate data about the status of transplanted patients due to FSGS encouraged us to obtain data from all pediatric nephrologists in Iran to achieve better pre and post transplantation therapeutic management. Material and Methods: The personal data of the pediatric nephrologist as well as the data of surgical and medical management prior to transplantation, relapse in the allograft kidney, and the therapeutic response rate after relapse were collected via a questionnaire. Results: Of 82 cases of FSGS from 1998 to 2018, 23 had relapse, mostly within 1 year after transplantation. When relapse occurred, nearly all centers used plasmapheresis and rituximab and some used angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) in addition to immunosuppressive medications and methyl prednisolone pulse therapy. Genetic studies were done in only two centers and there was no difference in immunosuppressive medications between these two centers and the idiopathic group. Pre-transplant plasmapheresis and rituximab were administered in four centers, while two centers used IVIG and one center only used plasmapheresis. Delayed graft function (DGF) was negative in 7 and positive in 9 centers. In most centers, immunosuppressive therapy consisted of a corticosteroid, mycophenolate mofetil, and tacrolimus. Relapse and recovery rates varied from less than 10% to more than 50% in all centers. Seven centers had no response to any medication. The lowest relapse rates were seen in two centers that had deceased donors and used rituximab and plasmapheresis prior to transplantation. Conclusion: It can be concluded that with regard to the possibility of relapse after transplantation and variable therapeutic management modalities before and after transplantation, it is reasonable that genetic analysis of mutations, identification of idiopathic and high-risk cases, and use of appropriate therapeutic protocols should be considered to decrease the relapse rate. Keywords: FSGS; Renal transplantation; Nephrotic syndrome; Child.Ureteral ectopia is a common condition presenting as incontinence in females and incidentally detected in males. The diagnosis requires thorough radiological investigations to delineate the anatomy and formulate the treatment. The prognosis is generally excellent. We presented a series of three cases of ureteral ectopia and discussion regarding their management. Keywords: Female; Urinary Incontinence; Ectopic Ureter; Duplex Moiety Kidney.Congenital Nephrotic Syndrome (CNS) is an autosomal recessive (AR) disorder characterized by massive proteinuria, hypoalbuminemia, and severe edema, starting in the first 3 months of life. Intussusception on the other hand is a surgical condition requiring a leading point in most of the cases. The occurrence of intussusception in congenital nephrotic syndrome may be due to bowel edema as the leading point. In this report, we present monozygotic twins with congenital nephrotic syndrome, who experienced the first episode of intussusception at ten months of age and then had repeated episodes until they were 18 months old. In our patients, mesenteric lymphadenopathy was reported by a radiologist that could serve as a leading point. Upon laboratory examinations, we could not find any explanation for this report. Intussusception must be one of the differential diagnoses of abdominal pain in nephrotic syndrome patients since prompt diagnosis and appropriate treatment can prevent further complications. Keywords: Congenital nephrosis; Intussusception; ChildAcute kidney injury (AKI) is reversible deterioration of renal function in which waste products accumulate and fluid imbalance occurs. The epidemiology of AKI has been changing over years. The aim of this study was to evaluate the epidemiology of AKI in hospitalized children in Iran. A literature search from March 2000 to March 2014 was conducted through MEDLINE, EMBASE, Scholar.google, IranMedex, MagIran, SID, and manual reference search of identified articles. Retrospective and prospective cross-sectional studies with a clear definition of acute kidney injury or failure were included. Seven out of twenty three articles which were found met the criteria. The incidence of AKI declined from 36% (2006-2008) to 15.4% (2010-2011) in the PICU setting of three referral teaching hospitals in Tehran. According to the classification, 10% had pre-renal failure, 86% had intrinsic renal failure, and 4% had post-obstructive uropathy. Follow-up was limited to the days of hospitalization. The overall reported mortality rate was 18% in pediatric departments. Acute glomerulonephritis including hemolytic uremic syndrome was the most common underlying disease (46.5%). Acute tubular necrosis was reported in 33% of the cases. One third of the cases of acute renal failure occurred in children less than two years. The real incidence of acute kidney injury might be higher considering a unified standard definition. Acute glomerulonephritis and acute tubular necrosis comprised the majority of the etiologies. Keywords: Acute Kidney Injury; Middle East; Iran; Etiology; Child; Incidence; Review Systematic.A 4-year-old male was transferred to pediatric emergency room because of acute abdominal pain. He was healthy before and had a history of felling down 2 weeks ago. Physical examination revealed an anxious and ill child with temperature of 37.5°C, pulse of 102/min, respiratory rate of 28/min and blood pressure of 100/70 mmHg. In abdominal exam the patient showed signs of acute abdomen. He was transferred to operating room and the first surgical diagnosis was kidney hematoma. Post operation kidney ultrasound reported large unilateral kidney hematoma. Post operation abdominal CT scan was shown in (Fig.1) (a,b).A 3-year-old girl was admitted with typical hemolytic uremic syndrome (HUS) and conservative treatments were initiated. During hospitalization, she had seizures, right hemiparesis, and loss of consciousness. Initial MR of the brain showed changes of acute disseminated encephalomyelitis (ADEM). She was treated with intravenous methylprednisolone and immunoglobulin. Upon improvement of her clinical condition, she was discharged with oral prednisolone which was tapered after two months. After one year fallow-up, the child now has a normal renal function and normal neurodevelopment.How to Cite This Article: Hooman N, Hallaji F, Mostafavi SH, Sharif MR, Tatarpoor P, Otukesh H. Bladder Volume Wall Index in Children with Urinary Tract Infections. J Ped. Nephrology 2013 July;1(1):18-22. Introduction : Few studies have focused on the correlation between bladder ultrasound and urinary tract infection. The aim of this study was to evaluate the bladder volume wall index in children with single or recurrent urinary tract infection. Materials & Methods : This case-control study was conducted between March 2008 and December 2009. The study was performed on one hundred children (8 boys, 92 girls) aged 4-15 years with a history of urinary tract infection and thirty-nine (20 males, 19 females) age- matched healthy children who had negative urine culture one month before investigation. The kidneys, ureters, and bladder sonography were performed in all children. Bladder volume wall index was calculated for each child and the result of 70-130 was presumed normal. Student T-test, chi-square, likelihood ratio, and risk ratio were used. P-value 130) in 38 children (28 cases, 10 controls) (P>0.05). The median residual volume was not different between the two groups. The abnormal BVWI in children with vesicoureteral (VU) reflux was 75% as compared to 51% in those without VU reflux (P>0.05). There was no correlation between BVWI and age, gender, groups, vesicoureteral reflux status, or residual volume (P>0.05). Conclusions : According to our findings, the bladder volume wall index is not sensitive enough to discriminate children who are prone to urinary tract infection. Keywords : Urography; Urinary Tract Infections; Ultrasonography; Urinary BladderTHE ASSOCIATION BETWEEN HYPONATREMIA AND REFLUX-RELATED RENAL INJURY IN ACUTE PYELONEPHRITIS Parsa Yousefichaijan, Hassan Taherahmadi, Mohammad Rafiei,Fakhreddin Shariatmadari, Saed Alinejad, Yazdan Ghandi ,Mahdyieh Naziri ABSTRACT Introduction: The kidney regulates sodium balance and is the principal site of sodium excretion. Sodium is unique among electrolytes because water balance, not sodium balance, usually determines its concentration. Although water balance is usually regulated by osmolality, volume depletion stimulates thirst, renal protection of water and ADH secretion. Volume reduction has priority over osmolality; volume depletion stimulates ADH secretion, even if a patient has hyponatremia. The aim of this study was to consider scar nephropathy in children with UTI and hyponatremia and compare it with children without hyponatremia. Material and Methods: 200 children with pyelonephritis were included in this case–control study as case and control groups, respectively. Subjects were selected from children referred to the pediatric clinic of our hospital in Arak, Iran. Case group included children with hyponatremia and UTI (with VUR) and control group included children with UTI (With VUR) and normal serum sodium. Data was analyzed using SPSS ver.18 Results: Among 200 (100%) children in both groups, 5 children (5%) had normal sodium and reflux nephropathy and 23 children had hyponatremia and reflux nephropathy. Conclusions: Hyponatremia in children with reflux nephropathy was significantly more common than children without reflux nephropathy. The observed correlation between reflux-related injury and hyponatremia necessitates evaluation of electrolytes in children with pyelonephritis. Keywords: Pyelonephritis; Child; Hyponatremia; Vesico-Ureteral Reflux.Introduction: Urinary Tract Infection (UTI) is one of the most common pediatric infections. UTI may create cystitis or pyelonephritis by involving bladder or renal parenchyma, respectively. Pyelonephritis, especially in pediatric patients, can lead to scar formation in kidneys and consequent complications such as hypertension, proteinuria, dysfunction and chronic renal insufficiency. The current study aimed to determine risk factors of acute rental cortical lesions in renal scintigraphy in children with UTI. Materials and Methods : Fifty-three patients with significant renal cortical lesions and 53 cases without significant renal cortical lesions were compared based on the intensity of findings of DMSA scintigraphy within the first two weeks of diagnosis. Patients were divided into three groups of 1 month to 2 years, 2 to 4 years and 4 to 10 years. Results: Of 106 patients, 11 males (20.8%) and 42 females (79.2%) had significant acute renal cortical lesions, whereas 15.1% of males and 84.9% of females had no significant acute renal cortical lesions. There was a significant difference in the degree of fever, the average interval between the onset of fever and treatment, mean level of CRP, leukocytosis and ESR in the two studied groups. The presence of Vesicoureteral Reflux (VUR), low initial hemoglobin and low initial BMI as random findings were associated with significant renal cortical lesions. Gender, age, grade of VUR and type of organism in urine culture had no significant association with significant renal cortical lesions. Conclusions: In this study, delaying in treatment, high degree fever, leukocytosis, high initial ESR and CRP, existence of VUR and low initial BMI and hemoglobin levels were associated with an increase in the value of acute renal cortical lesions, so in these cases, DMSA scan is suggested. Keywords : Urinary Tract Infections; DMSA (Dimercaptosuccinic Acid); Renal scars; Pediatrics.A case of refractory systemic lupus erythematosus was admitted with repeated tonic colonic seizures, intractable vomiting, diarrhea, and headache. Neurologic examinations, lumbar puncture analysis, and electroencephalogram were normal but magnetic resonance imaging of the brain showed dilated ventricles and sulci. Despite standard induction therapy, the patient gradually entered a confusional state, disorientation that changed to abnormalities in verbal and working memory, and finally no verbal communication for several days and avoided eating food and taking oral drugs. The patient achieved partial remission of the disease (improved symptoms of psychosis and renal function despite a high titter of anti-double strand DNA and positive anti-nuclear antibodies) with plasmapheresis, intravenous immunoglobulin, and anti-psychotic medication. Our case is interesting because he was refractory not only to standard treatments, but also he did not respond to therapeutic options that are used in refractory systemic lupus erythematosus and presented with psychosis that is an unusual clinical presentation in SLE . Keywords: Lupus Erythematosus, Systemic; Lupus Vasculitis, Central Nervous System; Psychotic Disorders; Child.Introduction: Although hospital acquired acute kidney injury (hAKI) is common and significantly increases the risk of hospital mortality, little is known about its frequency in developing countries where ICU facilities are limited. The purpose of this study was to investigate the frequency, cause, and outcome of hAKI in critically ill children in a tertiary level hospital. Materials and Methods : In this prospective cross-sectional study, a total 36 critically ill patients with hAKI were analyzed. hAKI was diagnosed according to the AKIN criteria. The clinical data of the patients admitted to the Pediatrics and Allied Departments in this hospital from November 2014 to October 2015 were collected. Results: A total of 3950 patients were admitted during the study period and 1103 (27.9%) were critically ill patients. Among the critically ill children, 36 (3.3%) were diagnosed with hAKI. Among different age groups, the highest incidence (5.05%) of hAKI was seen in children aged above 10 years. Sepsis was the major cause of hAKI accounting for 44.1% followed by antibiotics (27.1%), hypovolemia (13.6%), nephrotoxic agents (10.2%), and contrast agents (5.0%). Renal replacement therapy was required only in 8.3% of the cases. Conclusions: In comparison to other studies, this study showed a low incidence of hAKI where ICU facilities are limited. Among the hospital admitted critically ill patients, a significant number of patients may develop AKI mostly due to sepsis and use of antibiotics. Keywords : Hospital acquired AKI; Sepsis; Critically ill children; IncidenceIntroduction: Urinary Tract Infections (UTIs) are common in childhood and are frequently associated with abnormalities of the urinary tract. UTIs are the leading cause of morbidity in patients with neurologic bladder; this causes recurrent UTIs and Chronic Kidney Injury& Disease (CKD) that affects their quality of life. Children with UTIs are mostly neurologically intact, but may have infections as a result of a voiding dysfunction. The present study aimed to examine the relationship between occult bladder dysfunction and recurrent UTIs in our patients. Material and Methods : A cross-sectional study was done on 210 children aged 10 months to 15 years presenting with UTI with/without reflux who were admitted to the Nephrology Ward of Mofid Children’s Hospital between April 2011 and September 2013 using convenient sampling. Statistic analyses were conducted using descriptive statistics, Kolmogorov-Smirnov test, Mann Whitney test, Fisher’s Exact test, and odds ratio, and p values <0.05 were considered significant. Results: Of 210 Children 74% were female and 26% were male. 25% had one, 25% had two, 31% had 3, and 19% had more than 3 episodes of UTI. Eighty percent of the female and 56% of the male children had recurrent UTI (P: 0.004, odds ratio: 0.361). Fifty eight percent of the patients had Vesicoureteral Reflux which was bilateral in 34% of them. There was no correlation between UTI and Urinary Reflux (P=0.152, odds ratio=1.591) and also no correlation was detected between urodynamic findings and urinary reflux(P=0.243, odds ratio=1.485). Seventy six percent of the children with recurrent UTI had abnormal urodynamic results. Conclusions: Since many children with recurrent UTI and multiple renal scars have bladder dysfunction, it is recommended that urodynamic studies should be included in the evaluation of every child with recurrent UTI and renal scar. Keywords : Urinary Tract Infections; urodynamics; Vesico-Ureteral Reflux; ChildIntroduction: The opioid overdose epidemic is a worrying and considerable public health problem in many countries. A few studies have been done in children about opioid poisoning. The aim of this study was to explain the clinical symptoms and laboratory findings of opioid poisoning and the associated complications among children. Material and Methods : This prospective cross-sectional study was conducted on 100 children under 14 years of age who were poisoned with opium, tramadol, buprenorphine, methadone, and diphenoxylate and admitted to Loghman-Hakim Hospital, a major center for poisoning treatment in Tehran, Iran, from April 2011 to April 2012. The exclusion criteria were a history of musculoskeletal diseases, concurrent ingestion of other drugs, intramuscular injection, and a history of trauma. The clinical presentation and renal and electrolytes complications were recorded. Results: Finally, 90 out of 100 admitted children were eligible to be included in the study, 64 boys and 26 girls (median age: 40.3 ± 32 months, range: 1 month to 11 years old). The minimum duration of admission was 1 day and the maximum was 29 days with a mean of 2 days. The major opioid substance was methadone. The most common symptom was decreased consciousness followed by bradypnea. The incidence of opioid- induced rhabdomyolysis was 2.2% but none of the them were complicated with acute renal failure or electrolyte disturbance. Conclusions: Concerning this study, we recommend attention to muscle enzymes elevation and preventive spadework for its complications in children poisoned with opoiods. Keywords : Opium; Poisoning; Rhabdomyolysis; Acute Kidney Injury; child.Prenatal Risk Factors for Infantile Reflux Nephropathy Parsa Yousefichaijan, 1Fatemeh Safi, 2Mohammad Rafiei, 3Hassan Taherahmadi, 4Gholam Ali Fatahibayat, 5Mahdyieh Naziri6* 1 Department of Pediatric Nephrology,Arak University of Medical Sciences,Arak, Iran. 2 Department of Radiology, Arak University of Medical Sciences. 3 Department of Biostatistic, Arak University of Medical Sciences. 4 Departmnet of Pediatrics, Arak University of Medical Sciences. 5 Departmnet of Neonatology, Arak University of Medical Sciences. 6 Msc in Statistics Introduction: Vesicoureteral reflux (VUR) refers to the retrograde flow of the urine from the bladder to the ureter and kidney. In children with a febrile urinary tract infection (UTI), those with re_lux are 3 times more likely to develop renal injury compared to those without reflux. Reflux nephropathy was once accounted for as much as 15-20% of end-stage renal disease in children and young adults. With greater attention to the management of UTIs and a better understanding of reflux, end-stage renal disease secondary to reflux nephropathy is uncommon. Reflux nephropathy remains one of the most common causes of hypertension in children. Reflux in the absence of infection or elevated bladder pressure does not cause renal injury. We sought to determine the association of infantile reflux nephropathy (IRN) with prenatal risk factors. Materials and Methods: In this study, 96 infants with re_luxrelated renal injury and 96 infants with VUR without re_lux nephropathy were evaluated. Maternal information was assessed. Data was analyzed using SPSS version 18. Results: The results of this study showed that age more than 35 years, pre-gestational hypertension, preeclampsia and eclampsia, preterm delivery, very low birth weight (VLBW), pre gestational diabetes mellitus, and maternal BMI<18.5kg/m2 (underweight) were prenatal risk factors for infantile reflux nephropathy. Conclusions: The data suggests that prenatal factors may affect the risk of IRN. Adequate prenatal care and good maternal support can be effective in the prevention of reflux-related renal injury. Keywords: Vesico-Ureteral Reflux; Risk Factors; Prenatal; Infant.Introduction: Pediatric urolithiasis is an uncommon disease with incidence varying widely throughout the world. We present our experience in pediatric PCNL in 20 pediatric patients with urolithiasis. Materials and Methods : Case records of all patients under 14 years of age who presented with urolithiasis from 2016 March to February 2017 were retrospectively reviewed and analyzed with respect to demographic details, clinical presentation, stone characteristics, PCNL puncture site, number, stone clearance, ancillary procedures used, complications, and follow-up status of the children. Associated biochemical abnormalities were also reviewed. Results: There were 25 renal units in 20 patients (5 had bilateral stones). The mean age at presentation was 8.4 years. There were 15 males and 5 females. The most common presenting symptom was flank pain (n=19/20). There were solitary stones in 17 renal units: 2 stones in 6 renal units and multiple stones in 2 renal units. The average stone size was 1.5cm. Four patients had staghorn calculi. Five patients required two punctures of whom 3 had bilateral disease and 2 had staghorn calculi. The sheath used ranged from 18 Fr to 22 Fr. The nephrostomy tube and DJ stent were kept in all patients. The duration of the procedure at a single site ranged from 45 minutes to 75 minutes. Complete clearance was achieved in 19 patients while one patient required bilateral URS. Three patients had mild fever post-operatively. None of the patients required blood transfusion. Hypocalcaemia was detected in 7 patients. Conclusions: PCNL is safe and effective for treating urolithiasis in children. Keywords : PCNL; Urolithiasis; Pediatric.