Does treated primary hypertension lead to end-stage renal disease? A 20-year follow-up of the primary prevention study in Goteborg, [Sweden]

Background. Hypertension is reported to be one of the most common causes of end-stage renal disease (ESRD) in Europe and in the United States. However, the frequency with which treated primary hypertension leads to renal failure is not known. The majority of patients with ESRD have hypertension. Whether this is the cause or the consequence of the impaired renal function is often not possible to establish. Methods. To determine if treated primary hypertension can lead to ESRD, we studied the development of serum creatinine levels in 686 white hypertensive men, recruited from a random third of the male population aged 47-55 years living in Goteborg, Sweden (n=9998; 7495 participants). At entry and during 20 years follow-up, all signs of kidney disease, secondary hypertension, or increase in blood pressure were investigated. Records of patients with a serum creatinine value ⩾130 &mgr;mol/l at any time during the observation period were thoroughly studied to ascertain the cause of the impaired renal function. Results. A serum creatinine level above 130 &mgr;mol was seen in 8.9% (61/686) of the treated hypertensives during the 20 years of follow-up. An underlying renal disorder was found in 7.2% (49/686) of the patients; renoparenchymal disease (2.2%), renovascular disease (1.5%), diabetic nephropathy (1.2%) or a urological disease (1.6%). Only 1.7% (12/686) of the hypertensives showed a moderate progressive increase in serum creatinine of unknown cause. The serum creatinine in this group was 133±8 &mgr;mol/l (mean±SD; range 124-144) after 15 years and 139±7 &mgr;mol/l (range 132-151) after 20 years had developed ESRD or a clinically important reduction in renal function. Conclusion. The main finding in this population-based study of white middle-aged men with primary non-malignant hypertension was that long-term antihypertensive treatment was not associated with development of end-stage renal disease or even an abnormal progressive decline in kidney function.     

Arterial hypertension following renal transplantation in children—a short-term study

Systemic arterial hypertension is a common complication among transplanted patients. The objective of this study was to investigate the risk factors for arterial hypertension after kidney transplantation in children. A retrospective study was carried out of 70 kidney transplants performed on patients under 18 years of age at the Hospital do Rim and Hipertensão, from January 1998 to June 2001. At the end of 6 months post transplant, the patients were classified into either normotensive (n=31) or hypertensive (n=39) groups. The following potential risk factors for arterial hypertension were studied: (1) hypertension before transplantation; (2) the glomerular filtration rate (GFR) at 1, 3, and 6 months post transplant; (3) acute rejection episodes; (4) cumulative dose of corticosteroids; (5) the presence of native kidneys; (6) symptomatic renal artery stenosis; (7) cold ischemia time greater than 24 h; (8) age and sex of the donor; (9) age of the recipient; (10) transplant type (living related or cadaveric donor); (11) the body mass index of recipients at the end of the follow-up period; and (12) delayed graft function. The two groups were comparable in terms of the etiology of renal insufficiency, age, gender, and immunosuppressive drugs. Among the risk factors studied, the sole factor showing a statistically significant association with arterial hypertension was the GFR at 3 and 6 months after transplantation. In the group of normotensive patients, GFRs were 92±29 and 83±20 ml/min per 1.73 m² at 3 and 6 months, respectively, whereas in the hypertensive patients, GFRs were 74±23 and 70±21 ml/min per 1.73 m² respectively. Hence, only the lower GFR can be considered a risk factor for hypertension in children within our sample. However, arterial hypertension might be a risk factor for the early onset of chronic allograft nephropathy; in this case, hypertension should be considered the cause of lower glomerular filtration. Our data do not permit us to distinguish between these two hypotheses. The known risk factors for hypertension following renal transplantation in adults were not confirmed in the present study. It remains unclear to us as to whether this means the etiology of hypertension differs in children, or if this is the result of a bias in patient selection.     

The Changing Pattern of Renal Amyloidosis in Indian Subcontinent: Two Decades of Experience from a Single Center

Background: Renal amyloidosis is a major cause of morbidity and mortality among the patients of systemic amyloidosis. The causes of amyloidosis vary from country to country and from time to time at individual center. Aim: This study investigates the changes in epidemiological and clinical profile of renal amyloidosis in recent years. Method: Cases of biopsy-proven renal amyloidosis from January 1992 to December 2010 were studied retrospectively. They were divided into two groups: 1990s (between 1992 and 2002) and 2000s (between 2003 and 2010). The clinical characteristics of patients were studied and compared between the groups. Result: A total of 2498 (974 in 1990s and 1524 in 2000s) renal biopsies was done during the 19-year period. The incidence of amyloidosis in 1990s and 2000s was 1.74% (n = 17) and 1.9% (n = 29), respectively (p > 0.05). We noted that the incidence of renal amyloidosis increased significantly (p < 0.05) among the females in 2000s. The mean age of patients in 2000s and 1990s was 38 ± 17.9 and 39.2 ± 19 years, respectively (p = 0.83). Renal insufficiency in patients with renal amyloidosis significantly increased (p < 0.05) in 2000s (n = 14; 48.2%) in comparison to 1990s (n = 2; 12.8%). Subnephrotic proteinuria was observed in 12.8% (n = 2) and 48.82% (n = 14) of patients in 1990s and 2000s, respectively (p <?0.05). Infection (n = 10; 58.8%) was the most common cause of secondary amyloidosis during the 1990s, whereas chronic inflammation (n = 14; 48.2%) was the most common cause in 2000s. In 1990s, the incidence of ankylosing spondylitis (AS) and rheumatoid arthritis (RA) was 11.7% (n = 2) and 5.8% (n = 1), respectively, but in 2000s, their respective incidence was 17.2% (n = 5) each. Multiple myeloma (MM) was the most common cause of amyloid light chain protein (AL) amyloidosis in both the groups. We observed systemic lupus erythromatosus (SLE)-related renal amyloidosis in two cases and Hodgkin lymphoma-associated amyloidosis in one case in 2000s. Conclusion: The overall incidence of renal amyloidosis showed little change from 1990s to 2000s. Chronic inflammatory diseases were the most common cause of renal amyloidosis in 2000s in contrast to infections in 1990s. Female gender was more affected in 2000s than in 1990s. Renal insufficiency and subnephrotic-range proteinuria were more frequent clinical manifestations of renal amyloidosis in recent years (2000s) in comparison to the earlier decade (1990s).     

Enamel hypoplasia of primary teeth in chronic renal failure

 Chronic renal failure (CRF) in the first years of life is associated with developmental defects of enamel in the permanent dentition. We investigated if CRF also affects the primary (deciduous) dentition. Thirty-one children with CRF on conservative treatment (n=12) or on renal replacement therapy (n=19) underwent dental inspection. In addition, 18 CRF children provided an exfoliated deciduous tooth for microscopic examination. Enamel defects were detected in a total of 12 children (31%), either clinically or microscopically. Of the 7 children affected clinically, 6 (19% of all examined) presented localized hypoplasia of the primary canines, which was found only in 3% of healthy control children: 1 patient had generalized pitted enamel hypoplasia. By microscopy, 5 of 10 primary canines examined showed enamel hypoplasia localized exclusively in enamel formed after birth. The ”birth line,” a visible structure within the primary enamel, was always present, which excludes a prenatal onset of the defects. Of the 12 patients with an enamel defect, 9 had a documented onset of CRF within the first 7 weeks of life. We conclude that renal disease leading to CRF may affect enamel formation of primary teeth in early postnatal life, resulting in lesions different from those observed in the secondary dentition. Received: 24 September 1997 / Revised: 24 June 1998 / Accepted: 25 June 1998     

Continuous arteriovenous haemofiltration in critically ill children

We report 24 children with acute renal failure treated with continuous arteriovenous haemofiltration (CAVH) between 1987 and 1991. The median age was 2.9 years (range 3 days to 9 years). The main causes of the acute renal failure were: open heart surgery (n=11) and liver failure of different origins before and after liver transplantation (n=10). The indication for CAVH was oliguria or fluid overload in all children. The femoral vessels were used as vascular access in most instances. Different filters were used, depending on the size of the patient and an average ultrafiltration of 130±89 ml/h was achieved, which resulted in a fluid clearance of 4.0±2.6 ml/min per 1.73 m². In 18 patients uraemia was adequately controlled. Nine children survived after recovery of their renal function; 15 (62.5%) died as a consequence of multiorgan failure. We conclude that CAVH is an effective method to support critically ill children with acute renal failure.     

Impact of age on renal graft survival in children after the first rejection episode

Infants are thought to be more immunoreactive and at a greater risk for developing irreversible rejection compared with older children. We investigated this by analyzing patient and graft survival rates, incidence of acute rejection, reversibility of acute rejection, development of a subsequent acute rejection, and incidence of graft loss due to rejection in 154 children (<18 years of age) after primary renal transplantation. Most patients (n = 139) were treated with quadruple immunosuppression (antibody, azathioprine, prednisone, cyclosporine). Treatment of the first acute rejection episode (ARE) consisted of antibody and increased prednisone (68%) or increased prednisone alone (30%), and was not significantly different between the age groups. Transplants were from living donors (LRD) in 80% of cases. Patients were followed for at least 1 year (mean 58±30 months); 68% (105/154) of recipients experienced 1 or more ARE. The incidence of ARE was significantly lower in patients <2 years of age (45%) compared with patients 2 – 5 (76%, P = 0.01), 6 – 12 (78%, P = 0.005), and 13 – 17 (76%, P = 0.009) years of age. There was no significant difference in the 1-, 2- and 5-year patient or graft survival rates, the development of a subsequent acute rejection, or the incidence of graft loss due to acute rejection when analyzed by age group. These data suggest that the impact of an ARE is similar for younger and older children in our population receiving predominantly LRD transplants and quadruple immunosuppression. Received April 25, 1995; received in revised form and accepted January 30, 1996     

Continuous peritoneal dialysis in children: a single-centre experience in a developing country

Continuous peritoneal dialysis (CPD) is the most commonly used modality of dialysis in children. Continuous ambulatory peritoneal dialysis (CAPD) has been an established form of therapy in adult patients with end-stage renal failure in India for more than a decade. There is a paucity of published experience of CPD in children from developing countries. We retrospectively studied children with end-stage renal failure (ESRD) that had been on CAPD over the past 10 years. Thirty patients with ESRD, mean age 13±8 years (range 5–21 years), male 18, were started on CAPD from 1994 to October 2004. The mean break-in period was 12±3 days. Of these 30 patients, 15 had a total of 21 episodes of peritonitis. The peritonitis rate was 0.58 episodes per patient year. E. coli was the commonest organism causing peritonitis. On outcome analysis, 7/30 (23.3%) patients received a renal transplant, while 11/30 (36.6%) continued on CAPD, awaiting a kidney transplant. Of the rest, eight (26.6%) patients died, two (6.7%) suffered technique failure and were changed to haemodialysis, and two (6.7%) were lost to follow-up after 2 months. The mean cumulative survival time of patient on CPD was 42 months. We conclude that CPD is a viable option for dialysis in ESRD children in a developing country and is a successful bridge between ESRD and renal transplantation     

Clinical,pathological, therapeutic and prognostic analysis of primary membranous nephropathy in 218 children

Objective To analyze the clinical and pathological features, treatment and prognosis of primary membranous nephropathy (PMN) in children. Methods A retrospective study was conducted in patients with PMN diagnosed by renal biopsy in the Eastern Theater General Hospital from July 1, 2008 to September 30, 2017. The data of patients' general information, laboratory examination, renal pathology and therapeutic regimen were collected. The effects of different drugs in treatment and prognosis of PMN children were analyzed. Results Among 218 patients with PMN, the ratio of male to female was about 1.32∶1. The age group from 13 to 18 years old (adolescent) accounted for 87.6%, and there was no significant difference in age between the sexes (P=0.839). The main clinical manifestation was nephrotic syndrome (157 cases, 72.0%). The most common renal pathology stage was stageⅡ(101 cases, 46.3%). The positive rates of IgG1 and IgG4 in immunofluorescence staining were 100.0% and 98.5%, respectively, and IgG4 (45 cases, 33.8%) was the most common deposit. The positive rates of serum anti-PLA2R-Ab and kidney tissue PLA2R immunostaining were 53.97% and 82.54%, respectively. The total remission rate of PMN in children treated with tacrolimus combined with steroid was 83.6% and the recurrence rate was 33.3%. After follow-up time of 45.0(23.5-74.0) months, 11 cases (5.0%) developed end-stage renal disease (ESRD). The cumulative survival rates of ESRD at 5 and 10 years after renal biopsy were 95.4% and 63.7%, respectively. The cumulative renal survival rates of ESRD or a 30% decline in eGFR at 5 and 10 years after renal biopsy were 92.7% or 55.9%. Univariate Cox regression analysis demonstrated that hypertension and heavy proteinuria (24-hour urinary protein≥50 mg/kg) predicted a high risk of ESRD, and renal pathologic parameters were not associated with disease progression. Multivariate Cox regression analysis showed that hypertension (HR=9.517, 95%CI 1.181-76.715, P=0.034) and heavy proteinuria (HR=3.946, 95%CI 1.126-13.832, P=0.032) were independent risk factors for developing ESRD in PMN patients. However, the effectiveness of Cox regression analysis was analyzed by PASS software, and it was concluded that hypertension was not related with disease progression. Conclusions PMN should be considered in adolescent patients with nephrotic syndrome. Tacrolimus combined with steroid is more effective than steroid combined with other immunosuppressive agents in treating PMN. After follow-up time of 45.0(23.5-74.0) months, the prognosis of PMN children is acceptable. Heavy proteinuria is an independent risk factor for developing ESRD in children with PMN.     

Ambulatory blood pressure monitoring in children after renal transplantation

Arterial hypertension is a common complication in children after renal transplantation and the control of hypertension is often difficult. This retrospective investigates the prevalence and rate of control of hypertension using ambulatory blood pressure monitoring (ABPM) in 45 children (mean age 14.1 +/- 4.3 years, mean time after renal transplantation 2.2 +/- 2.7 years), all on cyclosporine or tacrolimus, azathioprine or mycophenolate mofetil plus daily steroids. The overall prevalence of hypertension was 82%. None of the transplanted children had normal blood pressure without antihypertensive therapy (ie, spontaneous normotension). Twenty percent of children had untreated hypertension, 18% had controlled hypertension, and 62% had uncontrolled hypertension. Prevalence of the nondipping phenomenon was 53%. The mean number of antihypertensive drugs (without diuretic monotherapy) in treated patients was 1.9 drugs per patient. The prevalence of arterial hypertension in children after renal transplantation is high and the control of hypertension is often unsatisfactorily low.     

Malignant hypertension and its renal complications in black South Africans

Malignant hypertension is an important cause of morbidity and mortality among urban black South Africans. Hypertension accounts for 15.9% of all patients and for 34.6% of blacks receiving treatment for end-stage renal failure. Malignant hypertension is more commonly diagnosed than benign hypertension and two-thirds of patients present in the age group 30 - 49 years. Together they are the most common preventable cause of end-stage renal failure in this country. Acute partially reversible renal failure occurs in 20% of patients with malignant hypertension who require dialysis. This is an important subgroup, who may be recognised by their younger age, female preponderance and fulminant presentation. Short-term peritoneal dialysis and effective control of blood pressure will result in satisfactory return of renal function. However, only adequate country-wide control of hypertension will prevent these costly renal complications.     

Chronic renal failure in Iranian children

We investigated chronic renal failure (CRF) in 166 Iranian children (95 boys and 71 girls) from July 1991 to June 1999. The mean age at onset of CRF was 7.9±4.5 years. The most common cause of CRF was congenital urological malformations (78 cases). The second most common cause of CRF was hereditary nephropathy (21%). Glomerular diseases accounted for only 10% of children who later went on to develop renal failure. High rates of cystinosis and primary hyperoxaluria were seen, and these elevated rates could be due to a high prevalence of parental consanguinity. Eighty-six patients required renal replacement therapy, of whom the majority underwent hemodialysis. The prevalence of primary reflux as a cause of CRF was high compared with reports from western countries. Earlier diagnosis and management of urinary tract infections in this group could reduce the prevalence of reflux as a cause of CRF in this population. Received: 15 May 2000 / Revised: 2 October 2000 / Accepted: 5 October 2000     

ACE I/D gene polymorphism in primary FSGS and steroid-sensitive nephrotic syndrome

The role of angiotensin-converting enzyme (ACE) insertion/deletion (I/D) gene polymorphism in various renal disorders has been investigated. We evaluated the association between the clinical characteristics and ACE genotypes of Turkish children with primary focal segmental glomerulosclerosis (FSGS) and steroid-sensitive nephrotic syndrome (SSNS). Patients with FSGS (n=30) were classified into two groups: one with remission together with stable renal function (n=22) and the other without remission and with impaired renal function (n=8). We classified children with SSNS (n=43) that were followed for at least 4 years into two subgroups as having more frequent (n=19) and less frequent relapses (n=11). The DD genotype was more frequent in the SSNS group than that in controls (37% vs. 17%, ²=4.98, P=0.025). However, among SSNS subgroups, the frequency of the DD genotype was not different. The distribution of ACE genotype was similar among patients with FSGS and SSNS. There was no difference in the ACE I/D distribution between children with FSGS and normal controls (II 10%, ID 60%, DD 30% vs. II 13%, ID 70%, DD 17%). The frequency of the DD genotype was higher in FSGS patients with declining renal function (63%) than in those with stable renal function (18%) (P=0.031). Progressive renal impairment was significantly more frequent in patients with FSGS with the homozygous D allele compared with FSGS patients with ID and II genotypes. Our results indicate that the DD genotype may be a risk factor for the development of progressive renal impairment in children with FSGS; however, larger studies are required to confirm this.The abstract of this study was accepted as a poster for the 36th meeting of the European Society of Paediatric Nephrology, Bilbao, September 2002. This study was supported in part by a grant from the Istanbul University Research Fund (no T-849/17072000)     

Captopril scintigraphy in the study of arterial hypertension in pediatrics

Renovascular hypertension (RVH) is responsible for 10% of arterial hypertension in children. The early diagnosis of RVH permits specific treatment leading to the cure of hypertension and avoidance of parenchymal damage. Captopril renal scintigraphy (CRS) provides information on the renovascular cause of the arterial hypertension. To validate the usefulness of CRS in hypertensive children, clinical, scintigraphic, and radiological data from 20 patients (mean age 6.1±5.5 years) were reviewed. Two patients were newborns. All had renal ultrasound scans and 9 had aortograms. In 7 children, RVH was confirmed by angiography, and CRS was positive for RVH in 6 of these. CRS was negative for RVH in 12 of 13 children without RVH. CRS was non-diagnostic in 3 children with abnormal baseline renal scintigraphy and severely decreased relative renal function (<35%), 1 of whom had RVH. No side effects of captopril renography were observed. Captopril renography provides a logical, non-invasive, safe, and cost-effective approach in the evaluation of children suspected of having RVH.     

Twenty-four-hour ambulatory blood pressure monitoring in young children

 Twenty-four-hour ambulatory blood pressure monitoring (ABPM) has many advantages for the diagnosis and follow-up of hypertension at all ages. This technique has so far not been documented as applicable to the very young. We studied the feasibility of ABPM in 61 healthy children and in 40 patients with renal diseases and/or hypertension, aged less than 6 years. A satisfactory ABPM profile (recording time = 24 h and >30 good recordings) was obtained in 77% of the healthy children. The mean number of good blood pressure (BP) measurements per 24 h increased with age from 46 (3–4 years) to 58 (6 years). The mean (±SD) systolic and diastolic BPs of healthy 3- to 6-year-old children (n = 47) were 110±5/67±5 mmHg during the day-time and 100±5/58±5 mmHg at night. In addition to the nocturnal decrease in BP, ABPM detected a second, day-time dip in BP during bed rest after lunch. Ninety percent of patients with renal disease and/or hypertension had successful ABPM recordings for 24 h, with an age-dependent increase in the mean number of reliable readings from 34 (< 2 years) to 48 (4 years). In 5 of 10 children with hypertensive results obtained by casual BP measurements, elevated BP was not confirmed by ABPM. We conclude that ABPM is a useful tool for the diagnosis and evaluation of hypertension in children under 6 years of age. Received March 5, 1996; received in revised form and accepted May 6, 1997     

Efficacy and safety of prolonged amlodipine treatment in hypertensive children

To examine the long-term efficacy and safety of amlodipine in hypertensive children, data on prolonged use (6 months) of amlodipine in 33 children were reviewed. All children received amlodipine as sole therapy for their hypertension. Causes of hypertension included solid organ transplant (n=19), renal disease (n=7) primary hypertension (n=6), and drug-induced hypertension (n=1). Mean patient age at the start of amlodipine treatment was 9.8±4.8 years (range 1.3–16.9); there were 19 boys and 14 girls. Mean duration of amlodipine treatment was 20.4±11.5 months (range 6–48). Analysis of blood pressure and dosing data revealed that blood pressure reduction was sustained throughout the period of amlodipine treatment, while amlodipine dose remained stable (mean effective daily dose 0.17±0.12 mg/kg). No patient required discontinuation of amlodipine because of adverse effects. This small study suggests that prolonged amlodipine treatment is well tolerated in hypertensive children and provides sustained blood pressure control. Further studies are necessary to determine what effects if any long-term calcium channel blocker treatment has on the growth and development of children with hypertension.     

Frequency of renal diseases and clinical indication for renal biopsy in children (Report of the Italian National Registry of Renal Biopsies in Children)

Background. Children's renal biopsy data were gathered for 3 consecutive years (1992-1994) by the Group of Renal Immunopathology of the Italian Society of Pediatric Nephrology, which opened a paediatric section of the Italian Registry of Renal Biopsies. Materials. The Registry recorded the histological diagnosis and the clinical data at renal biopsy of 432 children ⩽15 years old (mean age 8.96±3.7 years). Results. The most common glomerulonephritis (GN) at renal biopsy was idiopathic IgAGN (18.8%) and the most frequent secondary GN was Henoch-Schonlein purpura (HSP) nephritis (11.6%). Minimal-change disease (MCD) accounted for 11.6%, focal and segmental sclerosis (FSG) 8.5%, mesangial proliferative GN (MPGN) 9.5%, membranoproliferative GN 5.5%, and thin-membrane disease 5%. Lupus nephritis was diagnosed in 5% and Alport's GN in 3.9% of the cases. The annual incidence of primary GN in Italian children was 11.1 cases per million children population (p.m.c.p.), IgAN accounting for 3.1 cases, MCD 2.3, and HSP nephritis 1.9 cases p.m.c.p. respectively. Italian children underwent renal biopsy because of isolated microscopic haematuria in 19.3% of the cases, non-nephrotic proteinuria with or without microscopic haematuria in 31.2%, and nephrotic-range proteinuria in 34.2%, less frequently (15.3%) because of acute or chronic renal failure. Children with persistent isolated microscopic haematuria had most frequently IgAN (34.9%) or thin-membrane disease (25.3%), while those with non-nephrotic proteinuria had IgAN (30.4%) and HSP nephritis (23%). In cases with nephrotic proteinuria renal biopsy showed MCD in 34.5% of the cases, FSG in 16.9%, and MPGN in 12.2%. When renal biopsy was performed in chronic renal failure chronic interstitial renal disease was detected in 62.5% of the cases. Conclusions. This National Registry provides data on the indications for performing renal biopsy in Italian children and on the frequency and annual incidence of histological lesions detected. IgAN, primary or related to HSP, was the most common nephritis in Italian children undergoing renal biopsy.     

Seizures following renal transplantation in childhood

 Few studies have investigated the incidence of seizures following renal transplantation in childhood. The aim of this study was to determine this incidence and to identify risk factors. Retrospective casenote analysis was carried out on 119 transplants performed in 109 children over 10 years. Twenty-one transplants (in 20 children) were complicated by seizures, the majority of which occurred in the first 55 days after transplantation. Seizures were more common in the 5- to 10-year-old age group (P=0.03), but were no more common in those with a prior history of seizure (P=0.69). Their aetiology was predominantly multifactorial; hypertension (n=15), fever/infection (n=4) and acute allograft rejection (n=6) were commonly identified risk factors; 2 were secondary to intracerebral pathology. Most seizures were short lived, required minimal therapy and had a good long-term neurological outcome. In conclusion, seizures are relatively common following paediatric renal transplantation. Parents are now routinely counselled of this risk. Received: 11 March 1998 / Revised: 15 May 1998 / Accepted: 9 September 1998     

Peritoneal dialysis for acute renal failure in children

Fifty infants and children with acute renal failure were treated with acute peritoneal dialysis between 1987 and 1990. The patients were dialyzed using either a catheter introduced percutaneously over a guide-wire (n=40) or a Tenckhoff catheter (n=10). The cause of the acute renal failure was primary renal disease in 17 children, cardiac disease in 19, and trauma/sepsis in 14. Peritoneal dialysis succeeded in controlling metabolic abnormalities, improving fluid balance, and relieving the complications of uremia. The procedure had few major complications. Overall mortality was 50%, reflecting the serious nature of the underlying diseases. We conclude that acute peritoneal dialysis is a safe and effective treatment in most pediatric patients with acute renal failure. Our series of patients treated with acute peritoneal dialysis serves as a basis of comparison for the evaluation of new modalities of therapy in childhood acute renal failure.     

Yield of renal arteriography in the evaluation of pediatric hypertension

The prevalence of renovascular disease is estimated to be 3%–5% in pediatric patients with hypertension. The utility of non-invasive imaging tests has not been evaluated in children, and renal arteriography remains the diagnostic test of choice. However, there are no established guidelines for the application of this test and information is not available about the likelihood of detecting an abnormality if an arteriogram is performed in children with hypertension. Therefore, we reviewed the yield of renal arteriography in pediatric patients if the test was performed based on the following two criteria: (1) severe hypertension exceeding the 99th percentile for age and sex or (2) failure to control high blood pressure with one antihypertensive drug. During the period 1983–1998, 28 children (mean age 11.7 years) who satisfied one of the above criteria underwent renal arteriography to investigate hypertension. None of the patients were renal transplant recipients. The average duration of hypertension was 11 months and the peak blood pressure was 168/107 mmHg. The renal arteriogram was abnormal in 12 patients (43%). Unilateral renal artery stenosis was the most-common abnormality. When the patients were divided into two groups – those with an abnormal or normal test result – they did not differ in age, sex, or racial distribution. The peak systolic blood pressure was higher in children with an abnormal renal arteriogram (P<0.05). Among those undergoing the arteriogram on the basis of the first criterion, i.e., severe hypertension, 11 of 23 (48%) studies were abnormal. Five children had an arteriogram based on the second criterion – failure to control the blood pressure with one medication – and in 1 patient (20%) the test was abnormal. We conclude that the prevalence of renovascular disease in a population of hypertensive children subjected to renal arteriography is around 40%. Two clinical criteria – namely severe hypertension or failure to control hypertension effectively with one drug – are useful to guide the application of renal arteriography in children with hypertension. Received: 12 August 1999 / Revised: 24 November 1999 / Accepted: 28 November 1999     

Risk of hypertension in primary vesicoureteral reflux

The aim of this report was to estimate the risk of hypertension in children with primary vesicoureteral reflux (VUR). Between 1970 and 2004, 735 patients were diagnosed with VUR at a single tertiary renal unit. Of 735 patients, 664 (90%) were systematically followed and had multiple measurements of blood pressure. Hypertension was defined as values persistently above 95th for age, sex, and height in three consecutive visits. Risk of hypertension was analyzed by the Kaplan-Meier method. Of 664 patients followed, 20 (3%) developed hypertension. The estimated probability of hypertension was 2% (95%CI, 0.5%–3%), 6% (95%CI, 2%–10%), 15% (95%CI, 11%–20%) at 10, 15, and 21 years of age, respectively. The prevalence of hypertension has increased with age: it was 1.7% for patients with 1 yr–9.9 yr, 1.8% for adolescents with 10 yr–14.9 yr, 4.7% for patients with 15–19.9 yr, and 35% for patients >20 years at the end of the follow-up (P < 0.001). It was estimated by survival analysis that 50% of patients with unilateral and bilateral renal damage would have sustained hypertension at about 30 and 22 years of age, respectively. Hypertension increased with age and was strongly associated with renal damage at entry in an unselected population of primary VUR.