Prognostic value of serum creatinine levels in children with posterior urethral valves treated by primary valve ablation

PurposeWe evaluated the prognostic value of serum creatinine level at presentation and nadir creatinine during follow up for future renal function (RF) in children with posterior urethral valves (PUV).Materials and methodsBetween 1987 and 2004, 120 cases of PUV were treated initially at our hospital with valve ablation. Initial assessment included serum creatinine measurement, urine analysis and culture, renal ultrasonography and voiding cystourethrography. After valve ablation, renal ultrasound and serum creatinine measurement were repeated and thereafter during visits until the end of follow up.ResultsFollow up ranged from 2 to 12 years (mean = 4.4). Renal insufficiency (RI) developed at the end of follow up in 44 patients (36.5%). The mean initial and nadir serum creatinine in the RI group was higher than in the normal RF group (P < 0.05). With a cut-off value of 1 mg/dl for initial and nadir serum creatinine, the incidence of RI was significantly different (P < 0.05).ConclusionOur data confirm the high prognostic value of nadir serum creatinine after relief of valvular obstruction. Further, the serum creatinine level before valve ablation correlates significantly with long-term RF in children with PUV.     

Association of angiotensin converting enzyme and angiotensin type 2 receptor gene polymorphisms with renal damage in posterior urethral valves

ObjectiveTo examine the association with renal damage in patients with posterior urethral valves (PUV) of two renin–angiotensin system gene polymorphisms: angiotensin converting enzyme insertion/deletion (ACE I/D) and angiotensin type 2 receptor (AT2R A1332G),Patients and methodsIn 120 patients with PUV, after stabilization, transurethral fulguration or a Blocksom vesicostomy was performed. Records were reviewed for age at diagnosis, biochemical renal function at diagnosis, results of urine cultures, voiding cystourethrograms, radiologic, sonographic and nuclear medicine scan findings, and follow-up data. ACE I/D genotypes were determined by the polymerase chain reaction using allele specific primers.ResultsThe frequency of the ACE DD genotype was significantly higher in patients with chronic kidney disease (P = 0.02) and renal scarring (P = 0.05). These genotypes were also associated with a statistically higher incidence of vesicoureteral reflux, diurnal incontinence, proteinuria and hypertension. A significantly higher frequency of the AT2R GG genotype was found in PUV patients as compared to healthy unrelated control subjects (P = 0.001), and in PUV patients with scarring (P = 0.02).ConclusionThe ACE DD and AT2R GG genotypes are associated with chronic kidney disease and scarring in PUV patients. The GG genotype incidence is higher among PUV patients compared to the control population, and further studies in this area may help understanding of the genetic basis of PUV.     

Long-term upper and lower urinary tract functions in children with posterior urethral valves

ObjectiveSeveral factors have been identified as predictive of future renal function in children with posterior urethral valves (PUV). Our aim was to analyse upper and lower urinary tract outcome in patients with PUV, and determine any factors from the period of early management that were predictive of future renal function.MethodsThe charts of 67 boys (mean age 2.4 years) diagnosed with PUV were reviewed. The most common presenting symptom was dribbling in 43.2% and UTI in 28.3%. Twenty-three (34.8%) patients developed end-stage renal disease aged 1–15 years. The mean time of renal survival was calculated as 7.8 (SEM = 0.73) years.ResultsIncontinence in patients over 5 years old, lower urinary tract dysfunction, serum creatinine level in first year or at the time of diagnosis, and presence of vesicoureteral reflux and high-grade bilateral reflux were significant risk factors for occurrence of renal failure in the future. Lower tract dysfunction was seen in 58.6% of patients. Postnatal diagnosis and presence of high-grade reflux were significant risk factors for the future occurrence of lower urinary tract dysfunction.ConclusionIt is important to recognize that PUV have consequences not only during childhood or before treatment, but also during or after the treatment period. Long-term assessment and follow-up of upper and lower urinary tract functions after valve ablation is necessary.     

Angiotensin-converting enzyme gene polymorphism in North-west Indian children with posterior urethral valves

PurposeTo investigate the association of angiotensin-converting enzyme (ACE) gene insertion/deletion (I/D) polymorphism and other risk factors with renal scarring in patients with posterior urethral valves (PUV).Materials and methodsForty consecutive patients from North-west India were treated for PUV in 1997–2004. The patients were divided into group 1 (no renal scarring, n = 12) and group 2 (renal scars present, n = 28) based on dimercato-succinic acid scans. ACE I/D polymorphism was determined by polymerase chain reaction in PUV patients and unrelated healthy controls (n = 100).ResultsMean age at presentation was 23.7 ± 37.2 months and mean follow up was 4.8 ± 1.5 years. Preoperative mean serum creatinine levels for group 1 (non-scarred) and group 2 (scarred) were 1.1 ± 1.6 mg/dl and 1.7 ± 1.6 mg/dl, respectively. One year after treatment, the serum creatinine levels had decreased to 0.6 ± 0.1 mg/dl and 0.8 ± 0.3 mg/dl in group 1 and group 2, respectively. ACE genotype distribution in children with PUV was no different from that of controls. The occurrence of D allele was significantly (p = 0.04) higher in patients of group 2. Multivariate logistic regression analysis showed that D allele had a significant impact on renal scar formation, introducing a 4.6-fold risk (odds ratio 4.6, 95% confidence interval 1.03–20.38, p = 0.04). A highly significant correlation between the occurrence of renal scarring and presence of breakthrough urinary tract infection (odds ratio = 7.5, 95% confidence interval 1.60–35.07, p = 0.006) and serum creatinine at follow up (odds ratio = 0.6, 95% confidence interval 0.47–0.81, p = 0.03) was observed. The mean values for glomerular filtration rate (GFR) after 1 year of treatment (p = 0.006) and at follow up (p = 0.027) were significantly different between the patients with II genotype and ID/DD genotype. Hypertension was observed in 13 patients and proteinuria in nine patients with no significant difference between the patients having II/I D/DD genotypes.ConclusionThe presence of D allele is associated with progression of renal scarring and reduced GFR in PUV patients.     

Voiding school for children with idiopathic urinary incontinence and/or bladder dysfunction

ObjectiveIndividually applied urotherapy is first-line treatment in children with bladder dysfunction. A new concept of treatment for small groups of children was applied and evaluated.Patients and MethodsTwo hundred children, 116 of them girls, aged 3–14 years (median 7.2) with bladder dysfunction and incontinence received urotherapy in small groups (2–5), called voiding school (VS). Outcome was evaluated after 3 and 12 months by voiding/leakage diary and questionnaire, and at 3 months by uroflow and post-void residual urine as well.ResultsThe outcome of VS was independent of age and gender. At follow up at 3 and 12 months, respectively, 35% and 40% of the children were cured and another 30% and 34% improved (P ≤ 0.0001). Compared with the year before start of VS, urinary tract infections decreased from 34% to 6% (P < 0.0001). Median residual urine decreased from 15 ml before VS to 6 ml after 3 months (P < 0.001).ConclusionThe concept of VS is a good alternative to individual urotherapy, with the outcome of fewer urinary tract infections and improved continence. Urotherapy for groups of children compared to individual treatment is also expected to have financial benefits.     

Severe bladder dysfunction revealed prenatally or during infancy

ObjectiveAlthough thought to be an acquired condition, non-neurogenic neurogenic bladder may sometimes be a congenital dysfunction, revealed before toilet training. We report our experience with the condition diagnosed prenatally or during early infancy.Patients and methodWe retrospectively reviewed cases of severe bladder dysfunction with upper-tract impairment, without neurological or obstructive pathology, in children diagnosed before toilet training: five with prenatal diagnosis of severe hydro-ureteronephrosis (group 1) and six with signs of bladder dysfunction during infancy (group 2).ResultsFollow up of group 1 showed decompensation toward severe bladder dysfunction, diagnosed after either toilet training or ureteral reimplantation (n = 3). After a median follow up of 14 years (0.5–20), four were on clean intermittent catheterization with bladder augmentation and one required sphincteric re-education with good result. Two of the five had chronic renal failure. In group 2, six children (two females) presented at median age of 20 months (2–30) with indirect signs of bladder dysfunction, including vesicoureteral reflux (n = 4) and/or hydro-ureteronephrosis (n = 4). After a median follow up of 11 years (5–20), three were on clean intermittent catheterization (two Mitrofanoff channels), and three underwent bladder augmentation. Three children had chronic renal failure of whom one underwent renal transplant.ConclusionThese cases of severe bladder dysfunction were initially misdiagnosed. In both groups, follow up revealed severe dilatation of the upper tract and secondary renal impairment. Antenatal diagnosis of bilateral pyeloureteral dilatation may be the first sign of early bladder dysfunction.     

Management of calculus anuria in children: Experience of 54 cases

ObjectiveTo evaluate the outcome of different treatment plans for calculus anuria in children.Patients and methodsPatients were subdivided into three groups, A, B and C. Group A included patients who were critically ill, had serum creatinine ≥ 3.5 mg/dl, blood urea ≥ 100 mg/dl, serum potassium ≥ 7 meq/l and/or blood pH ≤ 7.1; and they were treated initially by peritoneal dialysis. Patients in groups B and C were stable with serum creatinine < 3.5 mg/dl, blood urea < 100 mg/dl, serum potassium level < 7 meq/l and blood pH > 7.1. In group B, the obstructing stone could not be localized, and they were treated either by percutaneous nephrostomy or JJ stent. In group C, stone level was confidently determined and patients were treated by open surgery.ResultsFifty-four patients were included. All patients regained normal serum creatinine levels within 72–120 h. Overall complication rate in groups A and C was 26% and 13%, respectively. In group B, overall complication rate was 66% for percutaneous nephrostomy and 50% for internal stent.ConclusionsUrinary diversion in children is associated with a high complication rate while dialysis is highly effective in children. Formal surgery in compensated children is associated with a low complication rate with good outcome and early recovery.     

Post-pyelonephritic renal scars are not associated with high voiding pressures

ObjectiveThe aim of this study was to evaluate whether renal scars and vesicoureteral reflux (VUR) are associated with bladder dysfunction in children after first clinical pyelonephritis.Patients and methodsSixty-four children were evaluated with urodynamics and voiding cystourethrography at a median of 8 weeks after their first episode of clinical pyelonephritis. All patients had ultrasonography and dimercaptosuccinic acid (DMSA) scintigraphy during the infection. After 2 years, DMSA scintigraphy was repeated in 58 patients. Re-infections were recorded.ResultsOveractive detrusor was found in 27 (42%) patients. There was no significant difference in the incidence of overactive detrusor between boys and girls. The maximal voiding pressure was higher in boys (median 92.5, range 48–191 cmH₂O) than in girls (median 82, range 37–150 cmH₂O) (P = 0.0117). Thirty-one (48%) patients had renal defects in scintigraphy during the infection. Ultimately, 12 patients (21%) developed renal scars; 11 patients (17%) had VUR. Renal defects in DMSA scintigraphy and the presence of VUR were not associated with overactive detrusor or high voiding pressures.ConclusionOveractive detrusor is a common finding after first episode of pyelonephritis. The dysfunction may explain the development of urinary tract infections in some children. There were no differences in the incidence of overactive detrusor or voiding pressures in patients with and without VUR, or in those with and without renal defects on DMSA scintigraphy. Urodynamic study is not a primary investigation in pyelonephritic children.     

La punción suprapúbica guiada por ecografía aumenta el rendimiento de la técnica en menores de 4 meses

IntroductionSuprapubic bladder aspiration (SBA) is a widely accepted technique used to collect uncontaminated urine samples from infants with suspected urinary tract infection (UTI). Ultrasound-based guidance improves the success rates. The standard measurements for a successful procedure, however, have been scarcely evaluated.ObjectiveTo assess the efficacy of ultrasound-guided SBA versus blind SBA, and to establish the bladder measurements associated with optimal results.Patients and methodUltrasound-guided SBA was performed in 50 infants ≤ 4 months of age with suspected UTI, and the anteroposterior (APD) and transverse diameter of the bladder were determined using ultrasound equipment (Esaote MyLab^® 25 Gold, and Hewlett Packard Sonos^® 5500) with a 3.5 MHz convex probe. The success rates and the total volumes of collected urine were compared to a control group of 50 patients of similar age and clinical characteristics, to whom conventional blind SBA was performed.ResultsThe rate of successful ultrasound-guided SBA was 92.3% compared to 30.8% in the blind SBA group (P < .05). The collected urine volumes were 7.65 ± 1.85 ml and 6.1 ± 2.13 ml, respectively (P < .001). An APD ≥ 2 cm was associated with an optimal performance of the technique (97.8% success). No major complications were observed in either group.ConclusionsUltrasound-guided SBA is significantly more successful than blind SBA in infants less than 4 months of age, with an APD ≥ 2 cm being optimal for conducting the procedure.     

Adrenocortical status in infants and children with sepsis and septic shock

BackgroundThe benefit from corticosteroids remains controversial in sepsis and septic shock and the presence of adrenal insufficiency (AI) has been proposed to justify steroid use.AimTo determine adrenal state and its relation with outcome in critical children admitted with sepsis to PICU of Cairo University, Children Hospital.MethodsThirty cases with sepsis and septic shock were studied. Cortisol levels (CL) were estimated at baseline and after high-dose short ACTH stimulation in those patients and in 30 matched controls. Absolute AI was defined as basal CL < 7 μg/dl and peak CL < 18 μg/dl. Relative AI was diagnosed if cortisol increment after stimulation is <9 μg/dl.ResultsOverall mortality of cases was 50%. The mean CL at baseline in cases was higher than that of controls (51.39 μg/dl vs. 12.83 μg/dl, p = 0.000). The mean CL 60 min after ACTH stimulation was higher than that of controls (73.38 μg/dl vs. 32.80 μg/dl, p = 0.000). The median of %rise in cases was lower than that of controls (45.3% vs. 151.7%). There was a positive correlation between basal and post-stimulation cortisol with number of system failure, inotropic support duration, mechanical ventilation days, and CO₂ level in blood. There was a negative correlation between basal and post stimulation cortisol with blood pH and HCO₃.ConclusionRAI is common with severe sepsis/septic shock. It is associated with more inotropic support and has higher mortality. Studies are warranted to determine whether corticosteroid therapy has a survival benefit in children with RAI and catecholamine resistant septic shock.     

Evaluación del grosor del complejo íntima-media de la carótida en la hipercolesterolemia familiar durante la infancia

IntroductionFamilial hypercholesterolemia (FH) is characterized by exposure to severely elevated LDL-cholesterol from birth, which produces lipid deposits, which can be measured by means of intima-media thickness (IMT).Subjects and methodsThe IMT and concentrations of cholesterol and its fractions, triglycerides, alipoproteins Apo-A1, Apo-B and endothelial risk factors (homocysteine and high sensitivity protein C ) were determined in 89 patients (44 males) from 2 to 19 years (9.54±3.91 years). IMT was measured by ultrasound using a 12 MHz linear array transducer in both carotids to 1 cm of the bulb. The IMT mean was compared with age, sex and analytical parameters using multiple regression analysis.ResultsThe mean values were: IMT 0.334±0.088 mm, total cholesterol 273.62±91.93 mg/dl, LDL-cholesterol 204.21±86.16 mg/dl, LDL/HDL 3.83±1.45, apoprotein A1 134.61±26.49 mg/dl, apoprotein B 130.59±40.59 mg/dl, homocysteine (median) 7.16 mmol/dl, Protein C (median) 0.3 mg/l. Using multiple regression analysis, only age was associated with IMT (P=0.049), a mean 0.005 mm (95% CI: 0.000–0.010) being the annual increase: up to 12 years the increase in IMT was 0.002 mm/year on (95% CI: ?0.007–0,010) and then from that age it was 0.013 mm/year (95% CI: ?0.023–0.049).ConclusionsThe measurement of the carotid IMT could become an objective parameter in the evaluation of the FH in childhood. In our study, it is only associated with age, the increase being most marked from 12 years onwards.     

Función renal basal en pediatría: correlación de métodos que dependen de la recogida de orina de 24 h con otros más sencillos que no requieren orina minutada

IntroductionIn daily clinical practice a quick, easy and accessible method is needed to adequately assess renal function. The objectives of this study were: 1. To quantify the relationship and concordance of the glomerular filtration rate (GF) calculated by the clearance of creatinine in 24 h urine (CCr) and the original and modified Schwartz equation (SE); and 2. To correlate urine elimination of substances that depends on the volume of excreted urine in a unit of time with other parameters that are calculated measuring the concentration of these substances in blood and urine.Material and methodsThe study included 401 healthy children with ages between 3 to 14 years (187 male and 214 female). The analysis between the variables was carried out using Pearson's correlation coefficient and the intraclass correlation coefficient (ICC).ResultsThe correlation between values of CCr and the original SE (non-standardised creatinine measurement) was r = 0.58 (P < 0.001) and the concordance, ICC = 0.74. The correlation between CCr values and the modified SE (standardised creatinine measurement) was r = 0.68 (P < .001), and the concordance ICC = 0.78. There was a very significant correlation between the elimination of sodium in a 24 h urine (mEq/kg/24 h) and the Na-Fractional-Excretion (EFNa): r = 0.8 (P < .001). There was a correlation between the potassium elimination in 24 h (mEq/kg/24 h) and EFK: r = 0.85 (P < .001). Between volume/min/1.73 m² and the urine volume percent of GF was: r = 0.88 (P < .001).ConclusionsThese equations provide valuable information of the state of the basal renal function without having to use a timed urine.     

Influencia étnica en la prevalencia de síndrome metabólico en población pediátrica obesa

IntroductionObesity in children is becoming more prevalent. Obesity and type 2 diabetes is higher in the Latin American immigrant population.ObjectiveTo analyze the influence of ethnicity on the prevalence of metabolic syndrome (MS) and its components in an obese pediatric population.Patients and methodsA retrospective study of 616 obese children and adolescents (BMI ≥ 2 SD [Hernández 88-04]), was conducted on 142 Latin American children and 474 Caucasians, which compared the prevalence of metabolic syndrome and its components according to modified Cook criteria (2003): obesity + 2 or more of the following components: HDL-cholesterol < 40 mg/dl, triglycerides > 110 mg/dl, systolic and/or diastolic blood pressure > p90 (Task Force 2004), and impaired glucose metabolism (ADA 2011). Hepatic function, family history of MS, HbA1c, insulin resistance (HOMA) and BMI evolution at one year of treatment with changes in lifestyle (diet and exercise) were also assessed.ResultsAlmost one-third (30.5%) of Latin American children had MS compared to 15.5% of Caucasians (OR = 2.4 [CI 95%: 1.5-3.8]), P<.005] and OR = 2.5 adjusting for sex, SD-BMI and puberty. Latin American children also had a higher insulin resistance (58.6% vs 42.8%, P<.005) and a worse outcome after one year of treatment.ConclusionThere is a higher prevalence of MS in our Latin American obese pediatric population with poor adherence to the measures of change in lifestyle, making these patients a group with potentially increased risks of cardiovascular disease in adulthood     

Could prophylactic antibiotics be stopped in patients with history of vesicoureteral reflux?

ObjectiveTo compare the incidence and type of urinary tract infection (UTI) in patients with primary vesicoureteral reflux (VUR) diagnosed after a febrile UTI while they were on prophylactic antibiotics (PA) and after stopping PA.Materials and methodsCriteria to discontinue PA were: no UTI during 12+ or more months on PA, old enough to communicate UTI symptoms, potty trained and absence of risk factors for UTI. Patients with at least 1 year of follow up without PA were included (n = 77). We recorded: age at which PA was indicated and stopped, time on and off PA, incidence and type of UTI (cystitis vs acute pyelonephritis (APN)), and renal scan results.ResultsPA was started and stopped at a mean age of 18.5 and 61 months, respectively. Mean time on PA was 39 months (range 12–95): 25 patients had 44 UTI episodes (0.17 episodes/patient/year), and 31 (70%) of them were APN. Mean time of antibiotics was 44.5 months (range 12–162): 13 patients had 24 UTI episodes (0.08 episodes/patient/year), eight (33%) of which were APN (P < 0.05). A renal scan was performed in 71 patients after the index infection and repeated in 12. Two patients lost renal function while still on PA.ConclusionDiscontinuing PA in patients with history of VUR is a safe practice and should be considered as a management option.     

Does bladder augmentation stabilize serum creatinine in urethral valve disease? A series of 19 cases

ObjectiveThis study evaluates the results of bladder augmentation (BA) in 19 boys with posterior urethral valves, especially as regards its efficacy in stabilizing serum creatinine.Patients and methodsIn the period 1995–2005, 188 patients with urethral valves were surgically managed. Nineteen of these had undergone BA as a part of their surgical management after initial endoscopic valve ablation in 15 and diversion in four boys. The mean serum creatinine at the time of BA was 2.11 mg/dl.ResultsBA stabilized the serum creatinine in 14 but failed to do so in five boys. A serum creatinine level of more than 2 mg/dl at the time of BA was associated with a significantly worse rate of success. BA as part of an undiversion procedure in three boys was unsuccessful.ConclusionIn an economic milieu where renal transplantation is not available for the majority of deserving children, careful selection is required before BA is considered as a surgical solution for the valve bladder. BA, when otherwise indicated, has been beneficial in children with pre-augmentation creatinine up to 2 mg/dl.     

Neutropenia febril posquimioterapia. Estancia hospitalaria y experiencia en nuestro medio

IntroductionInfections are significant cause of morbidity and mortality in cancer patients (mortality is estimated at around 3%). Febrile neutropenia often leads to the hospitalisation of cancer patients, increasing the risk of nosocomial infection, as well as health costs due to the hospital admission.MethodsAn ambispective (01 July 2015 – 12 July 2018) observational study was conducted on all episodes of chemotherapy-induced febrile neutropenia in a paediatric population. A record was made of age, gender, weight percentile (WHO), length of hospital stay (days), temperature (oC), microbial isolation, infectious source, antibiotic or antifungal prophylaxis, haemoglobin (g/dl), platelets (/mm³), neutrophils (/mm³), lymphocytes (/mm³), monocytes (/mm³), CRP (mg/L) and procalcitonin (PCT) (ng/ml) on admission, and days with neutropenia< 500/mm³. Statistical analysis was performed using the SPSSv.23 program.ResultsThe study included 69 patients, and 101 episodes were recorded. The mean stay was 7.43 days (median 6 days). Microbial isolation was found in 44.6% of the episodes, with no infectious source identified in 36% of them. An inverse correlation was found between haemoglobin, platelets, and lymphocytes on admission and the hospital stay (-0.356: P = .001, -0.216: P = .042, and -0.216: P = .042, respectively). The mean stay was greater if there was a CRP >90 mg/L (10.94 vs. 6.66 days, P = .017), if PCT >1ng/ml (16.50 vs. 6.77 days, P = .0002), if ≤ 100 neutrophils (8.27 vs. 5.04 days P = .039) on admission, and if there was microbe isolation (9.54 vs. 5.78 days P = .006).ConclusionThe relationship between haemoglobin, platelets, and lymphocytes on admission and the mean stay is inversely proportional. In addition, those patients with ≤100 neutrophils, CRP >90 mg/L, and PCT >1ng/ml on admission had a longer hospital stay.     

Immunoexpression of adrenergic receptors in detrusor from patients with prune belly syndrome: a digital quantification

IntroductionPrune belly syndrome (PBS) presents with large-capacity bladders, high compliance and post-void residual volumes. Operative and conservative treatments are controversial. When histologically compared to normal bladder, bladder outlet obstruction results in an up- or down-regulation of adrenoceptors. Our goal was to study the immunoexpression of adrenoceptors in detrusor from patients with PBS.Materials and methodsBladder domes from PBS patients (n = 14) were studied (PBG). For normal controls, bladder specimens were obtained at adult surgery (n = 13) (CG1) and at child autopsy (n = 5) (CG2). Staining was performed using antibodies to α1a, α1b, α1d and β3 adrenoceptors. Five to 10 images were captured on an optic microscope with a digital camera and analysed with Photoshop®. The immunocyhistochemical index with arbitrary units was calculated and compared.ResultsMean age was 1.28, 64 and 1.41 years for PBG, CG1 and CG2, respectively. The immunohistochemical index with arbitrary units of α1a receptors was 0.06 in PBG, 0.16 in CG1 and 0.14 in CG2 (p = 0.008); of α1b 0.06, 0.06 and 0.07 (p = 0.781); and of α1d 0.04, 0.04 and 0.05 (p = 0.618). Regarding β3 the respective values were 0.07, 0.14 and 0.10 (p = 0.378).ConclusionOur results show a decrease in α1a-adrenoceptor immunostaining intensity in detrusor from children with PBS. Further in vitro studies are needed to determine whether these observations are physiologically significant.     

Renal transplantation with and without bladder augmentation in children posterior urethral valve is there a difference in the long term?

PurposePosterior urethral valve (PUV) is a common etiology of end-stage renal disease(ESRD) in children. We compared children who underwent bladder augmentation prior to renal transplantation with those who underwent transplantation in the native bladder in regards to occurrence of UTI and long term renal function.Material and MethodsWe identified 40 patients with PUV from 1992 and 2006 who underwent renal transplantation in our institution. These patients were divided into two groups, Group 1: 20 patients who underwent bladder augmentation and Group 2 20 patients who did not undergo bladder augmentation. Graft dysfunction was defined as an increase of >20% in creatinine levels.ResultsForty-four transplantations were performed, 21 in G1 and 23 in G2, 35 from deceased donors(16 in G1 and 19 in G2). Medium age at transplantation was 11 years (5 to 17). Bladder drainage was done using clean intermittent catheterization by external continent ostomy in 95% of patients. Average renal graft survival at one year was 88% for both groups, after 5 years values were maintained of 90% in G1 and 87% in G2. Acute rejection occurred in 15% of grafts in G1 and 26% in G2. Urinary tract infection (UTI) was found in 85% of G1 and 25% of G2. An increase in creatinine of 20% above the nadir was found in 33% of G1 patients and 10% in G2.ConclusionsPatients who underwent bladder augmentation had a higher incidence of infection and increase of creatinine levels, however these events did not affect renal graft survival when compared to non-augmented patients.     

Potassium disorders in pediatric emergency department: Clinical spectrum and management

IntroductionPotassium abnormalities are frequent in intensive care but their incidence in the emergency department is unknown.AimWe describe the spectrum of potassium abnormalities in our tertiary-level pediatric emergency department.MethodsRetrospective case-control study of all the patients admitted to a single-center tertiary emergency department over a 2.5-year period. We compared patients with hypokalemia (< 3.0 mEq/L) and patients with hyperkalemia (> 6.0 mEq/L) against a normal randomized population recruited on a 3:1 ratio with potassium levels between 3.5 and 5 mEq/L.ResultsBetween January 1, 2013 and August 31, 2016 we admitted 108,209 patients to our emergency department. A total of 9342 blood samples were tested and the following potassium measurements were found: 60 cases of hypokalemia (2.8 ± 0.2 mEq/L) and 55 cases of hyperkalemia (6.4 ± 0.6 mEq/L). In total, 200 patients with normokalemia were recruited (4.1 ± 0.3 mEq/L). The main causes of the disorders were non-specific: lower respiratory tract infection (23%) and fracture (15%) for hypokalemia, lower respiratory tract (21.8%) and ear–nose–throat infections (20.0%) for hyperkalemia. Patients with hyperkalemia had an elevated creatinine level (0.72 ± 1.6 vs. 0.40 ± 0.16 mg/dL, P < 0.0001) with lower bicarbonate (19.4 ± 3.8 vs. 21.8 ± 2.8 mmol/L, P = 0.0001) and higher phosphorus levels (1.95 ± 0.6 vs. 1.42 ± 0.27 mg/dL, P = 0.0001). Patients with hypokalemia had an elevated creatinine level (0.66 ± 0.71 vs. 0.40 ± 0.16 mg/dL, P < 0.0001) and a lower phosphorus level (1.12 ± 0.31 vs. 1.42 ± 0.27 mg/dL, P = 0.0001). We did not observe significant differences in pH, PCO₂, base excess and lactate, or in the mean duration of hospitalization in general wards and pediatric intensive care units according to the PIM and PRISM scores.DiscussionDyskalemia is rare in emergency department patients: 0.64% for hypokalemia and 0.58% for hyperkalemia. This condition could be explained by a degree of renal failure due to transient volume disturbance. The main mechanism is dehydration due to digestive losses, polypnea in young patients, and poor intake. In the case of hypokalemia, poor intake and digestive losses could be the main explanation. These disorders resolve easily with feeding or perfusion and do not impair development.ConclusionDyskalemia is rare in emergency department patients and is easily resolved with feeding or perfusion. A plausible etiological mechanism is a transient volume disturbance. Dyskalemia is not predictive of poor development in the emergency pediatric population.     

Diagnostic evaluation and management of seizures and status epilepticus in children with known epilepsy or new-onset seizures: A retrospective and comparative analysis

ObjectivesThe purpose of this study was to describe and compare the initial management, including clinical/biological investigation and treatment, of new-onset seizures and status epilepticus (SE) in children versus seizures and SE in those with known epilepsy.MethodsThis was a retrospective, single-center, observational study conducted in an urban pediatric hospital in Paris. All patients, aged from 1 month to 18 years, admitted to the pediatric intensive care unit, the high-dependency care unit, and those who required hospitalization in the short-term unit of the emergency department between January 1 and December 31, 2014 for seizures and/or SE were included.ResultsWe analyzed the data of 190 children: new-onset seizures (N = 118; group A) versus those with known epilepsy (N = 72; group B). At least one diagnostic test was performed on 156 patients (82.1%) (group A, N = 104, 88.1%; group B, N = 52, 72.2%; P = 0.05). In group B, blood levels of antiepileptic drugs were measured in 14 of the 38 patients with SE, of whom six were under dosed. Treatments were: first line, diazepam (group A, 80%; group B, 46%; P < 0.001); second line, diazepam (group A, 56%; group B, 34%; P = 0.02) or clonazepam (group A, 24%; group B, 46%; P = 0.001); third line, phenytoin (group A, 54%; group B, 22%; P < 0.001) or clonazepam (group A, 18%; group B, 61%; P < 0.001).ConclusionDiagnostic evaluation and treatment should be individualized for children with known epilepsy.