Prayong Vachvanichsanong

Childhood Acute Renal Failure: 22-Year Experience in a University Hospital in Southern Thailand

OBJECTIVES. The objectives of this study were to review the prevalence, cause, and morbidity and mortality rates of acute renal failure in a large tertiary care institution in southern Thailand, to examine any differences in acute renal failure cases diagnosed during a 22-year period, and to determine the risk factors indicating death. METHODS. The case records for children 1 month to 17 years of age who were diagnosed as having acute renal failure between February 1982 and December 2004, in the Department of Pediatrics, Songklanagarind Hospital, in southern Thailand, were reviewed. RESULTS. A total of 311 children with 318 episodes of acute renal failure were included, that is, 177 boys (55.7%) and 141 girls (44.3%), 1 month to 16.7 years of age (mean age: 7.6 ± 5.1 years; median age: 7.8 years). The causes of acute renal failure in each age group were significantly different. Overall, sepsis was the major cause of acute renal failure, accounting for 68 episodes (21.4%), followed by hypovolemia, poststreptococcal glomerulonephritis, systemic lupus erythematosus, and infectious diseases. Renal replacement therapy was performed in 55 cases (17.3%). The overall mortality rate was 41.5%. Logistic regression analysis showed that disease groups and creatinine levels were significant independent predictors of outcomes. CONCLUSIONS. The incidence of acute renal failure in Songklanagarind Hospital was 0.5 to 9.9 cases per 1000 pediatric patients, with a mortality rate of 41.5%. Sepsis was a major cause of acute renal failure and death. Causes of acute renal failure and serum creatinine levels were significant independent predictors of death.

Outcome of Dengue Hemorrhagic Fever-Caused Acute Kidney Injury in Thai Children

OBJECTIVES To examine the outcome of acute kidney injury (AKI) in children with dengue hemorrhagic fever (DHF), the cause(s) of AKI, and the risk of AKI and fatality. STUDY DESIGN The medical records of patients age <15 years during 1989 to 2007 were reviewed. DHF-caused AKI and patients with DHF with no AKI were matched 1:2 by age. RESULTS DHF-caused AKI was clinically estimated to be 0.9% (25/2893) of admissions, with a high mortality rate of 64.0%. Risk factors of AKI were DHF grade IV and obesity (odds ratio, 16.9; 95% CI, 4.2 to 68.5, and odds ratio, 6.3; 95% CI, 1.4 to 28.8, respectively). Respiratory failure, hepatic failure, and massive bleeding were complications found in 80.0%, 96.0%, and 84.0% of cases with AKI, respectively. Fatality was more likely in cases with DHF grade IV, oliguric AKI, respiratory failure, or prolongation of prothrombin or activated partial thromboplastin time more than twice that of reference specimens. Among the survivors, none had chronic kidney disease, and serum creatinine levels returned to normal in 32 (1 to 48) days. CONCLUSIONS Patients with DHF and AKI had a high mortality rate, although those who survived had a full return to normal function within 1 month. DHF grade IV and obesity were the major risk factors of AKI.

Urinary Tract Infection in Children Associated with Idiopathic Hypercalciuria

OBJECTIVE The aim of this study was to evaluate the association of symptomatic non-calculous idiopathic hypercalciuria (IH) with urinary tract infection (UTI) in children. MATERIAL AND METHODS This was a retrospective case review of children who had urinary calcium excretion greater than 2 mg/kg/day or random urine calcium-creatinine ratio (UCa/UCr) greater than 0.18 mg/mg. RESULTS One hundred and twenty-four consecutive children with clinical complaints and elevated urine calcium excretion were reviewed. Fifty children (40%) had UTI of which 39 (78%) had recurrent UTI. There was no difference in age between children with UTI and those without UTI. Twenty-four-hour urine calcium and random UCa/UCr were also not different. Only 4 children (8%) had renal stones whereas hematuria, abdominal pain and urine incontinence were frequent associated findings. Six of the children with recurrent UTI (15%) had an anatomical urinary tract abnormality. Therapy in all children consisted of increased fluid intake and reduction in diet sodium and oxalate; however, 14 of the 39 children with recurrent UTI (36%) required therapy with a thiazide diuretic. Recurrent UTI was abolished in 24 children, one child had a single recurrence and 4 children had no response to treatment. CONCLUSIONS We propose that non-calculous IH may be an important contributing factor to recurrent UTI in children.Objective: The aim of this study was to evaluate the association of symptomatic non-calculous idiopathic hypercalciuria (IH) with urinary tract infection (UTI) in children. Material and Methods: This was a retrospective case review of children who had urinary calcium excretion greater than 2 mg/ kg/day or random urine calcium-creatinine ratio (UCa/UCr) greater than 0.18 mg/mg. Results: One hundred and twenty-four consecutive children with clinical complaints and elevated urine calcium excretion were reviewed. Fifty children (40%) had UTI of which 39 (78%) had recurrent UTI. There was no difference in age between children with UTI and those without UTI. Twenty-four-hour urine calcium and random UCa/UCr were also not different. Only 4 children (8%) had renal stones whereas hematuria, abdominal pain and urine incontinence were frequent associated findings. Six of the children with recurrent UTI (15%) had an anatomical urinary tract abnormality. Therapy in all children consisted of increased fluid intake and reduction in diet sodium and oxalate; however, 14 of the 39 children with recurrent UTI (36%) required therapy with a thiazide diuretic. Recurrent UTI was abolished in 24 children, one child had a single recurrence and 4 children had no response to treatment. Conclusions: We propose that non-calculous IH may be an important contributing factor to recurrent UTI in children.

Diffuse proliferative glomerulonephritis does not determine the worst outcome in childhood-onset lupus nephritis: a 23-year experience in a single centre

INTRODUCTION Lupus nephritis (LN) is the major indicator of morbidity and mortality in systemic lupus erythematosus (SLE). Many studies have found a significantly worse patient survival rate in patients with LN class IV than patients with other LN classes. OBJECTIVE The aim was to describe the severity and outcomes of LN in a group of Thai children. METHODS We retrospectively reviewed the patient files of children diagnosed with SLE aged < or =18 years in Songklanagarind Hospital, Southern Thailand, from 1985 to 2007. RESULTS Of 216 SLE patients, 180 had renal biopsy results, and the others were excluded from analysis. There were 33 males and 147 females, average age 11.8 +/- 2.6 years (range 3.6-18.0), with a median follow-up period of 3.9 years (range 9 days to 19.4 years). Using the WHO LN classification, there were 9, 55, 5, 94 and 14 patients of classes I-V, respectively, as well as 2 with end-stage renal disease and 1 with IgM nephropathy. The mortality rate was 23% (42/180). Patients with LN class II had a similar renal and patient survival compared to patients with LN class IV (P = 0.3 and 0.2, respectively). Cox proportional hazard regression analysis in 177 patients (3 patients who had a renal biopsy result outside the WHO classification were omitted) showed that gender was an independent risk factor for survival. Males had 2.6 times the hazard rate compared to females (95% CI 1.2-5.7, P = 0.03), but LN classification, age and timing of the renal biopsy were not significant. CONCLUSION Renal and patient survival in LN classes II and IV were similar. Gender was the only independent risk factor of mortality, with males at greater risk than females.

Recurrent abdominal and flank pain in children with idiopathic hypercalciuria.

Objective: To evaluate the role of idiopathic hypercalciuria (IH) as a cause of recurrent abdominal pain (RAP) in children. Patients and methods: We retrospectively reviewed the medical records of 124 children referred for various complaints who had 24‐h urine calcium excretion greater than 2mg/kg/d or random urine calcium‐creatinine ratio greater than 0.18mg/mg. Results: Fifty‐two children with various clinical complaints had RAP or flank pain. These comprised of 22 males and 30 females, 9 mo to 15.9 y of age, mean 6.7 3.5 y. A family history of urolithiasis was present in 50% of all the children. Only 6 of the 52 children with abdominal pain had renal stones. In addition to abdominal pain, 27 children had hematuria and 10 had urinary incontinence. Mild metabolic acidosis was present in three children, parathyroid hormone activity elevated in two and serum vitamin D activity was increased in nine. All children were treated with increased fluid intake and a reduction in dietary sodium and oxalate and some required treatment with thiazide and antispasmodics. Forty‐five cases responded to treatment, 5 failed to improve from therapy, and 2, which were not followed up as patients, were not available.

Urinary calcium excretion in healthy Thai children.

Abstract The objective of this study was to determine age-specific reference values for urinary calcium/creatinine ratios (UCa/Cr) of children in southern Thailand. Non-fasting urine samples were collected from a random population of 488 healthy children (282 males, 206 females) ranging in age from 17 days to 15 years. Samples were divided into six groups by age. Subjects whose calcium levels exceeded the 95th percentile within each age group were classified as having hypercalciuria. Pyuria, hematuria, proteinuria, urinary sodium, and potassium levels in children with normal UCa/Cr were compared with levels in children with high UCa/Cr. The 95th percentiles for UCa/Cr (mg/mg) by age were: <6 months, 0.75; 6 months to <12 months, 0.64; 12 months to <2 years, 0.40; 2 years to <5 years, 0.38; 5 years to <10 years, 0.29; and 10 years to <15 years, 0.26. Pyuria, hematuria, and proteinuria were no more prevalent in the 22 children with hypercalciuria than in children with normal urinary calcium levels. Urinary sodium/creatinine ratios (UNa/Cr) and urinary sodium/potassium ratios (UNa/K) were correlated with UCa/Cr (r=0.41, P<0.0001 and r=0.24, P<0.0001, respectively). Urinary potassium/creatinine ratios (UK/Cr) were not (r=0.05, P>0.1)). Children with high UCa/Cr ratios also had higher UNa/Cr and UNa/K (5.6±7.1 vs. 2.6±1.5, P<0.001 and 5.4±2.3 vs. 2.5±0.23, P<0.05, respectively) The study established reference values for random, non-fasting UCa/Cr for healthy Thai children and indicated that urinalysis is not a good indicator of hypercalciuria.

Acute renal failure in a child associated with acyclovir

A 9-year-old boy developed acute renal failure following intravenous acyclovir (30 mg/kg per day) administered for 6 days to treat herpetic encephalitis. Physical findings and urine output were normal, except for increasing blood urea nitrogen (BUN), serum creatinine and mild proteinuria. Acyclovir was discontinued. However BUN and serum creatinine continued to increase and peaked on the following day at 8.6 mmol/l of urea (24 mg/dl) and 194 μmol/l (2.2 mg/ml), respectively. Conservative treatment and hydration were carried out. The kidney function returned to normal within 1 week. The use of acyclovir when necessary in renal failure patients is discussed.

Twenty-two years' experience with childhood-onset SLE in a developing country: are outcomes similar to developed countries?

Introduction The outcome of systemic lupus erythematosus (SLE) has dramatically improved since the introduction of corticosteroids; however, although many regimens of treatment have been supplemented, the mortality has not improved further. Objective To describe the severity and outcome in patients diagnosed with SLE aged ≤18 years in a group of Thai children, compare gender and age differences, and our outcomes with those from developed countries. Methods The authors retrospectively reviewed the files of patients aged ≤18 years diagnosed with SLE admitted to Songklanagarind University Hospital in southern Thailand, for the period 1985–2007. Patient survival rates were calculated. Results There were 213 SLE patients, 41 males and 172 females, average age 11.6±2.6 years, with a median follow-up of 3.6 years. Outcomes were alive (109), lost to follow-up (22), referred (31) or deceased (51). Of the patients who were alive, 23 were not on any treatment, 59 were on prednisolone alone while 27 were on prednisolone plus some other immunosuppressive drug. Total survival rates were 88%, 76% and 64% at 2, 5 and 10 years, respectively. Males had significantly worse survival than females at 2 and 5 years (78% vs 91% and 58% vs 80%, respectively, p=0.018). There were no differences in mortality between age groups. The 5-year survival rates in the periods 1985–1993, 1994–2000 and 2001–2007 were not significantly different. Conclusion This retrospective study of patients with SLE in southern Thailand showed different outcomes compared to some studies and similar survival rates and treatment status to other studies, with one-fourth of surviving patients being free of medication.

Timing of voiding cystourethrogram after urinary tract infection

Of the 363 Thai children upon whom a voiding cystouretrogram was performed, a vesicoureteral reflux was detected in 22.8% (17.1%–28.5%) of those for whom it was performed within 7 days (n = 215) of a urinary tract infection diagnosis and in 24.3% (17.4%–31.2%) of those for whom it was performed 7 days (n = 148) after diagnosis. There was no statistically significant difference in reflux prevalence between these two groups.

Urinary incontinence due to idiopathic hypercalciuria in children.

AbstractIdiopathic hypercalciuria is known to cause many nonstone urinary tract disorders in childhood. In addition to being the most common cause of microhematuria in children, our study demonstrates that idiopathic hypercalciuria is also frequently associated with urinary incontinence of all types. Of 124 children evaluated for idiopathic hypercalciuria 28 (23%) had urinary incontinence. Of the 28 children 15 (54%) had nocturnal, 6 (21%) diurnal, and 7 (25%) nocturnal and diurnal incontinence. The random urinary calcium-creatinine ratio, which was used to screen for hypercalciuria, should be part of the initial evaluation for urinary incontinence in children. Diagnosis may be confirmed by quantitative urinary calcium excretion. Most urinary incontinence in children that is due to idiopathic hypercalciuria responds to a combination of general treatment for hypercalciuria or thiazide diuretics.