Clinical quiz

A Rare Case of Renal Salt Wasting Associated with Metabolic Acidosis and Hyperkalemia

Farahnak Assadi, Elham Emami

Journal of Pediatric Nephrology, Vol. 9 No. 2 (2021), 14 April 2021 , Page 1-2

In the evaluation of patients presenting with chronic hyperkalemia hyponatremia and normal anion gap acidosis, pseudohypoaldosteronism types I and II are within the spectrum of differential diagnosis.
Recognition of these patients is important to prevent inappropriate mineralocorticoid therapy. Using clinical scenarios we aim to illustrate clinical mimics and dissimilarities to differentiate theses disorders.

Original Research Papers

Incidence of Acute Kidney Injury due to Contrast Usage in Patients Admitted to Mofid Children’s Hospital (2019-2020)

Nasrin Esfandiar, Mitra Khalili, Reza Dalirani, Zohreh Nickhoo

Journal of Pediatric Nephrology, Vol. 9 No. 2 (2021), 14 April 2021 , Page 1-6

Background and aims: Contrast-induced renal impairment endangers the patients' health and imposes a financial burden on families and the health care system. Therefore, this study was conducted to examine the rate of nephropathy in patients admitted to Mofid Children's Hospital in 2018 and 2019.
Methods: In this cross-sectional study serum creatinine was measured at baseline and 48-72 hours after CT
-scan an increase of more than 25% in serum creatinine was considered CIN. Paired samplet-test was used to assess the change in the Cr. The research data were analyzed using SPSS-25 software and the significance
level in all tests was set at P = 0.001.
Results: In this study,180 children underwent contrast-enhanced CT-scan with a mean age of 5.72 years, of whom 81 (45%) were girls and 99 (55%) were boys. The mean baseline creatinine was 0.633 ± 0.137 mg / dl, which increased significantly to 0.675±0.164 mg / dl 48-72 hours after the first measurement. The chance
of developing ARF in ciprofloxacin users was 4.86 times higher than patients who did not use this drug.
Conclusion: In children underwent CT scan, the incidence of ARF is 17.2%. Ciprofloxacin increases the risk of acute kidney problems by 4.8 times.

Safety and Efficacy of Rituximab in Children with Steroid-Dependent or Resistant Nephrotic Syndrome

Golshid Nourihosseini, Mehrdad Gazanchian, Yalda Ravanshad, Sahar Ravanshad, Anoush Azarfar, Mohammad Esmaeeli, Gholamreza Sarvari

Journal of Pediatric Nephrology, Vol. 9 No. 2 (2021), 14 April 2021 , Page 1-7

Backgroundand Aim:Rituximab is a novel therapy that can help patients with steroid-dependent or resistant nephrotic syndrome.The aim of this study was to evaluate the efficacy of rituximab in children with corticosteroid-dependent and resistant nephrotic syndrome and to determine the factors associated with its
Methods:In this study, 40 children with corticosteroid-dependent or resistant nephrotic syndrome who were treated with rituximab in Dr. Sheikh Hospital,Mashhad,between 2014 and 2018 were enrolled. Patients with a history of hematuria, severe urinary tract infection, or secondary nephrotic syndrome were excluded.
Results:The mean age of patients was 11.9 ± 5.04 years, and 55% were female. The most common underlying pathology of nephrotic syndrome was focal segmental glomerulonephritis (FSGS) (42.5%) followed by
membranoproliferative glomerulonephritis (MPGN) and minimal change disease (MCD). Most of the
participants (62.5%) were steroid-dependent and the rest (27.5%) were steroid resistant. Only 10% of the patients showed complications following rituximab administration and 57.5% went into complete remission. A negative family history and steroid-dependent nephrotic syndrome were significantly associated with a
better treatment response. Moreover, patients with steroid-resistant nephrotic syndrome were more likely to have a positive family history, while factors associated with steroid response included underlying pathology, gender, and family history.
Conclusion: Rituximab can cause remission in more than half of the patients with steroid-resistant or dependent nephrotic syndrome. Moreover, the only factors that reduce response to rituximab are a history of corticosteroid resistance and a positive family history of nephrotic syndrome.

Henoch-Schonlein Purpura in Northeast India: Peculiarities in Presentation

Rosina Ksoo, Himesh Barman, Biswajit Dey, Yookarin Khonglah, Lima Sangla, Saurabh Gohain Duwarah

Journal of Pediatric Nephrology, Vol. 9 No. 2 (2021), 14 April 2021

Background and Aim: Henoch-Schönlein purpura (HSP) is the most common childhood vasculitis characterized by leukocytoclastic vasculitis. This study was done to describe the presentation and immediate outcome of children admitted to HSP at our Institute.
Methods: This retrospective study was conducted on children with HSP admitted to our department over a period of 7 years (January 2010 until December 2016).
Results: Twenty-three children with a diagnosis of HSP were identified during the study period. The mean age was 9.4 years (4 years to 16 years). There were 15 girls and 8 boys with a male: female ratio of 1:1.9. The youngest child was 4 years old and most of the children (73.9%) were in the age group 5-12 years. Forty percent of the children presented between January and March. Major manifestations were rash (100%), joint pain (52%), renal involvement (52%), and abdominal pain (47.8%). Three (13.0%) children presented with systemic manifestations before the appearance of the rash. One child had MPGN 2 years before the onset of rash. There
was no mortality. Most of the children recovered well; six (26%) had persistent hypertension and three (13%) had persistent proteinuria. Hypertensive emergency was seen in two children. One child had intussusception that resolved spontaneously.
Conclusion: This study is the first study of Henoch Schonlein purpura from northeast India documenting certain peculiarities in the presentation. The results indicate a wide spectrum of presentations in HSP.

Microalbuminuria in Children: A Comparative Study of HIV-Infected and Non-Infected Children in Jos, Nigeria

Marcia M Ihekaike, Isaac E Ocheke, Stephen Oguche

Journal of Pediatric Nephrology, Vol. 9 No. 2 (2021), 14 April 2021

Background and Aim: Kidney disease occurs frequently in human immunodeficiency virus (HIV) infected individuals and is a leading contributor to morbidity and mortality in patients with HIV. Early detection
of kidney damage will aid in instituting interventional measures that could slow down or halt the progression of kidney disease. The aim of this study was to determine the prevalence and risk factors of microalbuminuria in HIV infected children in Jos, Nigeria and compare them with those of HIV negative children.
Methods: A total of 135 HIV infected and 135 HIV uninfected children aged 1-18 years were screened for microalbuminuria using microalbumin 2-1 combo test strips. Logistic regression analysis was used for determination of the association between microalbuminuria and various predicted risk factors.
Results: Thirty (22.2%) HIV infected and 13 (9.6%) uninfected children had microalbuminuria (p = 0.001). Logistic regression analysis showed that an increase in the WHO clinical stage was significantly associated with the presence of microalbuminuria in HIV infected children (p = 0.004).
Conclusion: The prevalence of microalbuminuria is higher in HIV infected children, as such the detection of microalbuminuria as early as possible in the course of the disease and prompt initiation of therapy are very important in our resource poor environment.

Clinical and Biochemical Parameters Changes after Using 0.9% Normal Saline as Maintenance Intravenous Fluid in Non-Critically Ill Children: An Experience from a Tertiary Care Hospital

Deepali Malviya, Shobha Sharma, Anita Rani, Kanika Kapoor, Namita Srivastava, Rani Gera

Journal of Pediatric Nephrology, Vol. 9 No. 2 (2021), 14 April 2021 , Page 1-9

Background and Aim: Recent recommendations are to use isotonic fluid as maintenance intravenous fluid (mIVF) in children. The most commonly prescribed fluid is 0.9% NS (normal saline) but there are concerns about hypernatremia, fluid overload and hyperchloremic metabolic acidosis leading to increased morbidity and even mortality mainly due to its adverse effects on kidneys.  This study was conducted to assess the clinical and biochemical effects of 0.9% sodium chloride as an isotonic mIVF in the general non-critically ill pediatric patients.

Methods: This observational study was conducted on admitted children requiring mIVF for a minimum 24 hours. Changes in the blood pressure and biochemical parameters like serum sodium, serum chloride and bicarbonate were evaluated and the incidence of hypo/hypernatremia, hyperchloremia and metabolic acidosis was calculated at 24 and 48 hours from baseline.

Results: Two hundred and fifty children were analyzed. The mean age of the patients was 3.79±3.2 years with majority (43.6%) in the age group 2 months- 1 year. There was no significant change in BP at any time point. The mean serum chloride level was 103.81±4.717, 104.5±4.581, and 105.28±4.545 at baseline, 24 hours and 48 hours respectively with a significant rise at 48 hours of mIVF (p-value< 0.001) and among 3 time points (p-value<0.01]. There was a significant decrease in the bicarbonate level at 48 hours from baseline (p<0.05).

Conclusion: According to the results, 0.9% NS as mIVF in non-critically ill pediatric patients causes a significant increase in the serum chloride level leading to hyperchloremia and metabolic acidosis.

Retrospective Audit of a Pediatric Nephrology Clinic at a Tertiary Care Teaching Hospital

Mritunjay Kumar, Rashmi Kumari, Kanchan Chand Thakur, Abhinav Tomar, Gaurav Batra, Pranayi Bose, Sakshi Bhuddi, Akhil Bangri

Journal of Pediatric Nephrology, Vol. 9 No. 2 (2021), 14 April 2021

Backgroundand Aim: To provide basic renal data in the pediatric age group in a poorly resourced
hilly state of India, which might be used by researchers and health planners.
Methods: The case records of children presenting to pediatric nephrology clinic from April 2016 to March 2017 were analyzed retrospectively.
Registered cases were broadly categorized into various groups and subgroups based upon clinical presentation
and investigation findings.
Results: Two hundred and five children presented to the pediatric nephrology clinic with renal diseases over a period of one year. Registered children presenting to pediatric nephrology clinic were broadly categorized into 10 groups. Nephrotic syndrome (NS) was the most common renal disease accounting for 45.6% of registered cases followed by congenital anomalies of the kidney and urinary tract (CAKUT) comprising 26.8% of the cases. Edema was the most common presenting symptom and proteinuria was the most common uri
nary finding. Focal segmental glomerulosclerosis was the most common histopathological finding reported on
renal histopathology and peritoneal dialysis was found to be the most frequently used modality for renal replacement therapy.
Conclusion: Our data reflects geographical variations of the patterns of renal diseases in a resource poor hilly state of northern India. Improvement in pediatric renal services and targeted training of health care workers
would help in early diagnosis and treatment of children with renal diseases resulting in reduction in their
morbidity and mortality.

Urinary Level of Interleukin-8 in Acute Pyelonephritis

Alireza Eskandarifar, Seyed abolhassan Seyedzadeh

Journal of Pediatric Nephrology, Vol. 9 No. 2 (2021), 14 April 2021

Backgroundand Aim: urinary tract infection is a prevalent disease in children. Determining the location of the bacterial invasion has a great impact on the treatment, follow-up, and complications. For this purpose, different laboratory and imaging methods are used, which are often invasive or unavailable. One of the non-invasive methods is to measure biomarkers such as interlukin-8 (IL-8) in the urine.The aim of this study was to evaluate the urinary level of interleukin-8 in acutepyelonephritis.
Methods: This cross- sectional study was carried out on 50 children aged 3-60 months. The children were
divided into two groups. The first group included children with acute pyelonephritis and the second group included healthy children who were randomly selected as controls. Then, the urine levels of IL-8 and creatinine were measured.
Results: The mean age of the subjects in case and control groups was 17.5 ± 22 and 22.5 ± 18.2 months, respectively (P = 0.92). The mean urinary ratio of IL- 8/Cr in the patient and control groups was 161.7 ± 90.1
and 12.2 ± 19.6 Pgr/mgr respectively, indicating a significant difference (P = 0.03). The results showed that a urinary IL-8/Cr ratio of 32 pg/mg was diagnostic according to the Receiver Operating Curve (ROC).
Conclusion: Urinary IL-8/Cr ratio can be used for early diagnosis of acute pyelonephritis


Case Reports

A Boy with Nephrotic Syndrome and Methemoglobinemia: A Diagnostic Challenge

Azmeri Sultana, Ranjit Ranjan Roy, Golam Muinuddin, Mohammad Anwar Hossain Khan, Shahabuddin Mahmud

Journal of Pediatric Nephrology, Vol. 9 No. 2 (2021), 14 April 2021 , Page 1-5

Methemoglobinemia is a rare disease characterized by the elevated levels of methemoglobin
in the blood. It may be congenital or acquired. Co-trimoxazole is an antibiotic that belongs to the sulfone
group. Sulfone group drugs may produce drug-induced acquired methemoglobinemia. Methemoglobin is an oxidized form of hemoglobin that has an increased affinity to oxygen and a reduced ability to release oxygen to tissues. High levels of methemoglobin inred blood cells cause tissue hypoxia. This disorder may present with
several symptoms such as cyanosis, fatigue, dyspnea, and headache. Because it is a rare cause of cyanosis and hypoxemia, the diagnosis of methemoglobinemia is often delayed. We herein discuss a five-year-old boy with steroid-resistant nephrotic syndrome who presented with exertional dyspnea and cyanosis and was later diagnosed as a case of co-trimoxazole-induced methemoglobinemia.

A 3- year- old boy presented with abdominal pain and distension, lower extremities and facial edema, and anuria for several days that was associated with ureteropelvic junction obstruction (UPJO). Initial ultrasonography showed the presence of a massive bilateral hydronephrosis with UPJO and a computerized tomography (CT) scan without contrast revealed a massive hydronephrosis and hydroureter
(grade 3). A follow-up study, after relief of ureteral obstruction, showed the reversal of this pattern. Blood biochemical tests revealed a severe acidosis, hyperkalemia, and a BUN/Cr ratio of more than 20.
The patient underwent emergency nephrostomy. The general condition of the patient improved. Abdominal distention reduced, levels of urea and creatinine decreased, and acidosis resolved. A CT scan revealed an almost complete disappearance of the hydronephrosis and a normal ureter. Ureteropelvic junction obstruction (UPJO) was established as the cause of giant hydronephrosis.

An 18-Year-Old Male Patient Presenting with Splenic Cyst and a History of Kidney Transplantation

Nahid Rahimzadeh; Hamzeh Mousavi, Mahan memarian; Aina Riahi

Journal of Pediatric Nephrology, Vol. 9 No. 2 (2021), 14 April 2021

The spleen is the most commonly injured solid organ in blunt abdominal trauma and contributes to mortality and morbidity. Epidermoid splenic cysts are an example of primary congenital cysts that contain an epithelial lining, unlike secondary cysts that are collection of fibrous tissue. An 18-year-old male presented with acute left upper abdominal pain, feeling of fullness, and dyspepsia since 10 days ago.  His past medical history was positive for renal transplantation from deceased donor five years prior to presentation.   Physical examination revealed normal findings except a palpable soft mass measuring 15x20 cm in the left upper quadrant (LUQ).

Successful Treatment of Unremitting Gastro-Intestinal Haemorrhage & Rashes of Henoch-Schӧnlein Purpura with Colchicine & Cryoprecipitate: A Case Report

Syed Saimul Huque, Abdullahel Amaan, Abdullah-Al Mamun, Tahmina Jesmin, Afroza Begum, Ranjit Ranjan Roy, Golam Muin Uddin

Journal of Pediatric Nephrology, Vol. 9 No. 2 (2021), 14 April 2021

Severe gastrointestinal manifestations and rashes of Henoch Schonlein Purpura (HSP) may not always respond to prednisolone or other immunosuppressive agent. Though reduced factor XIII may play a role in gastrointestinal manifestations but its role in management of skin rashes is uncertain. Here, we reported a case treated with different immunosuppressive agents but didn`t respond.  Thereafter, despite having the normal factor XIII assay, the unremitting GI symptoms and skin rashes, has improved after prescribing colchicines & infusion of Cryoprecipitate containing factor XIII.

Paraquat Poisoning and AKI –A Rare Pediatric Case Report in a Tertiary Care Hospital

Susmita Biswas, Paramita Barua, Mohammed Maruf-ul -Quader, Dhiman Chowdhury, Suman Biswas, Abir Das

Journal of Pediatric Nephrology, Vol. 9 No. 2 (2021), 14 April 2021

Paraquat is a widely used synthetic herbicide in agriculture. Ingestion of toxic doses of paraquat can be fatal with life threatening effects on the kidneys, lungs, gastrointestinal tract (GIT), liver, heart, and other organs. There is no specific antidote or effective life saving treatment for paraquat poisoning and its prognosis is very poor worldwide. Here we report a case that presented with acute renal failure, shock, GIT bleeding with oral mucosal ulceration, and pulmonary involvement due to accidental paraquat poi soning and delayed hospitalization after poison ingestion. In spite of partial improvement, the patient expired after two weeks of admission. Therefore, any case of paraquat poisoning must be hospitalized and, if needed, referred to equipped centers as early as possible after poison ingestion