Evidence Based Practice in Pediatric Urolithiasis

Hasan Otukesh, Rozita Hoseini

Journal of Pediatric Nephrology, Vol. 1 No. 2 (2013), 16 November 2013 , Page 46-51

Nephrolithiasis is an increasing problem in children. Due to the different presentations and etiology of this disease in children compared with adults, we decided to perform an extensive search to find trials and arrange an evidence based study in this regard.

Keywords: Urolithiasis; Child; Evidence-Based Practice

Special Reports

In recent years, based on controversial issues regarding the diagnosis, treatment and follow up in patients with febrile urinary tract infection (UTI), various investigations have been performed and conventional methods have been modified. Hence, American Academy of Pediatrics (AAP 1999 and 2011) and National Institute for Health and Clinical Excellence (NICE 2007) designed guidelines to justify a method for diagnosis, treatment and follow- up of UTI. The current revised version (AAP 2011) has important changes in approaching febrile UTI in 2- to 24-month infants such as the necessity of performing urinalysis and urine culture, revised sampling methods, modified treatment methods (parenteral or oral therapy), radiological follow-up, and finally antibiotic administration. The aim of this study was to summarize the recent AAP guideline (2011) and present a simpler algorithm.

 Keywords: Urinary Tract Infections; Infants; Child; Vesico-Ureteral Reflux

Original Research Papers

Causes of Recurrent Urinary Tract Infection in Children on Prophylaxis

Hadi Sorkhi, Hamid Shafi, Abass Hadipoor, Sohel Osia, Ornib Batebi

Journal of Pediatric Nephrology, Vol. 1 No. 2 (2013), 16 November 2013 , Page 56-60

 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; Child

Introduction: Hyperkalemia renal tubular acidosis (type IV) occurs secondary to impaired renal responsiveness to aldosterone. This can occur chronically in infants and children with a history of obstructive uropathy. The aim of this study was to assess of prognostic factors in children RTA type IV overwhelmed by bilateral obstructive uropathy.

Materials and Methods: In this study, we recruited and observed 48 male patients with both bilateral obstructive uropathy at the urinary bladder outlet and RTA type IV for two years. In this period, we registered patients’ demographic data; also, children’s growth, sonographic data, renal function tests and serum electrolytes underwent serial assessment and in if clinically indicated, the patients were treated with drugs like citrate sodium and Kay oxalate.

Results: Frequent urinary tract infection (p=0.0011), abnormal <20 weeks gestation sonography results like bilateral hydronephrosis (p=0.00001), birth weight below 2500 gr (LBW) (p=0.0014), preterm delivery (p=0.001), maternal age at birth below 20 years (p=0.0018), pregnancy more than 2 times (p=0.004), admission due to respiratory problems during infancy (p=0.003) and gestational diabetes (P=0.001) were significantly associated with a poor prognosis.

Conclusions: Considering the results of this study, it seems logical to consider abortion in case of renal hydronephrosis and dysplasia in gestational age below 20 weeks.

 Keywords: Hyperkalemia; Urologic Diseases; Renal Tubular Acidosis

Blood Chemical Analysis in Children with Acute Gastroenteritis, When Is It Useful?

Reza Tavakolizadeh, Manelie Sadeghi, Nasim Namiranian, Daryoosh Fahimi, Mohammad Barkhordari

Journal of Pediatric Nephrology, Vol. 1 No. 2 (2013), 16 November 2013 , Page 65-69

Introduction: Acute gastroenteritis (AGE) is one of the most common diseases in children. Intravenous (IV) fluid therapy may be indicated in some of them. The aims of this study were to assess the usefulness of blood chemical analysis (blood glucose, urea, creatinine, sodium, potassium and bicarbonate) and to define any clinical criterion that helps to predict usefulness before starting IV fluid therapy.

Materials and Methods: A cross sectional study was conducted at the Emergency Department of Bahrami Children Hospital from March 2011 to June 2012; all children with AGE who were between 3 months to 10 years without any underlying diseases were enrolled in the study. Demographic variables, medical history and physical examination, laboratory tests results, and dehydration grading (according to the World Health Organization criteria) were noted. The usefulness of laboratory tests was defined as any change in the treatment plan due to laboratory results.

Results: Four hundred and fifty nine children (55.3% boys, 44.7% girls, mean age 25.36 months) were assessed. There were statistically significant associations between the usefulness of tests and patients' age, frequency of passing diarrheal stool in the last 24 hours, and dehydration grade (p<0.001). Only dehydration grade could significantly predict usefulness according to a logistic regression model (p<0.05).

Conclusions: According to these results, routine blood chemical analysis may be useful in patients with moderate to severe dehydration.

 Keywords: Gastroenteritis; Child; Blood Chemical Analysis

Evaluation of quantitative urinary CRP (C-reactive protein) level in children with urinary tract infection

Ahmadali Nikibakhsh, Hashem Mahmoodzadeh, Sasan Hejazi, Mehran noroozi, Hojatollah Shfiei, Shahsanam Gheibi, Ahad Gazzavi, Ebrahim Sadegi, Negar Hosseinzadeh, Ezatollah Abasi

Journal of Pediatric Nephrology, Vol. 1 No. 2 (2013), 16 November 2013 , Page 70-73

Introduction: Urinary tract infection (UTI) is a risk factor for kidney damage and end stage renal failure. In this study, the urinary C-Reactive Protein (CRP) level was compared between patients with UTI and patients with other infectious diseases and the role of the mean urinary CRP, as a predictive factor for renal involvement, was evaluated.

Material & Methods: Urine samples were collected from patients under 15 years of age with UTI in Shahid Motahari Children's Hospital within 24 to 48 hours after hospital admission. Then, urine CRP was measured quantitatively using the ELISA method. The control group was selected among patients with various infectious diseases. Technetium Tc 99m Dimercaptosuccinic Acid (DMSA scan) and voiding cystouretrography (VCUG) were performed for children with UTI. Data were analyzed by using Mann-Whitney Test and P values less than 0.05 were considered statistically significant.

Results: A total of 50 patients with UTI as the study group and 20 patients as the control group were evaluated. The mean urinary CRP was 244.8 in the study group and 179.67 in the control group. There was no significant difference in urinary CRP between the cases and the controls (P value: 0.83). The mean urinary CRP was 83.4 ± 46.02 in 9 patients with DMSA scan class 1, 224.8±320.1 in 38 patients with class 2, and 399.53 ± 46.27 in the three patients with class 3. Mann-Whitney Test showed no significant differences in urinary CRP levels between normal and abnormal DMSA scans. Four patients were positive for VUR but there was no significant relationship between VUR and urinary CRP (P value= 0.56).

Conclusions: According to our findings, urine CRP does not have a diagnostic value in urinary tract infections in children and cannot predict renal damage.

Keywords: Urinary tract infections; C-reactive protein; Technetium Tc 99m Dimercaptosuccinic Acid

Is a Low Sacral Ratio Associated with Primary Vesicoureteral Reflux in Children?

Mehrzad Mehdizadeh, Seyed Taher Esfahani, Mohsen Rezaei Hemami

Journal of Pediatric Nephrology, Vol. 1 No. 2 (2013), 16 November 2013 , Page 74-78

Introduction: The association of sacral anomalies with fecal incontinence and lower urinary tract dysfunction is known. The sacral ratio is proposed as a tool for evaluation of sacral development. The aim of this cross-sectional study was to evaluate the prevalence and severity of vesicoureteral reflux in children with a low sacral ratio.

Materials and Methods: Six hundred and sixty nine children who were referred to a radiology clinic for a standard (fluoroscopic) VCUG to detect vesicoureteral reflux and other anomalies of the lower urinary tract after an episode of urinary tract infection were included in the study and their sacral ratios were measured.

 Results: All children were younger than 14 years of age (mean 3.44±3.20). Of 669 children, 593 (88.6%) had normal sacral ratios out of whom 423 (71.3%) did not have VUR and 170 (28.7%) had VUR. Seventy-six (11.3%) children out of 669 cases had low sacral ratios; 49 (64.5%) of them had no VUR and 27 (35.5%) had VUR. There was no significant difference in the prevalence of VUR between children with and without a low sacral ratio (p value=0.217). Also, there was no significant difference or trend between a low sacral ratio and the severity of reflux (Chi2 for trend).

Conclusions: Although sacral anomalies may be related to some cases of VUR by producing lower urinary tract dysfunction, the sacral ratio is not associated with VUR.

Keywords: Sacral agenesis; Vesico-Ureteral Reflux; Urination Disorders; Anorectal Anomalies; child

Case Reports

Recurrent Intussusceptions in both Twins with Congenital Nephrotic Syndrome

Mostafa Sharifian, Banafsheh Arad

Journal of Pediatric Nephrology, Vol. 1 No. 2 (2013), 16 November 2013 , Page 79-81

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; Child

Streptococcus Pneumonia-Associated Hemolytic Uremic Syndrome: A Case Report

Mohammad Saeed Sasan, Anoush Azarfar, Sepideh Bagheri

Journal of Pediatric Nephrology, Vol. 1 No. 2 (2013), 16 November 2013 , Page 82-84

Hemolytic uremic syndrome (HUS), a disease that destroys red blood cells, is the most common cause of sudden, short term acute kidney failure in children. By far, the commonest subgroup (>90% of childhood HUS) is induced by shiga toxin producing bacteria, usually enterohemorrhagic Escherichia coli (EHEC). These patients typically have a prodrome of diarrhea. Another important subgroup that is readily identified on clinical grounds follows invasive Streptococcus pneumonia infection. These infants tend to be younger than those with D + HUS, and the syndrome is very rare after the age of 4 years. They present with pneumonia, empyema, meningitis, and less often, isolated septicemia. Another group of patients may have mutations in complement regulators, and less often, inherited deficiency of von Willebrand protease or an inborn error of cobalamin metabolism. We report a 6-month-old child who developed hemolytic uremic syndrome following S. pneumonia meningitis.

Keywords: Hemolytic-Uremic Syndrome; Meningitis; Streptococcus pneumonia; Child

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