Predictors of renal scar in children with urinary infection and vesicoureteral reflux

We evaluated the predictors of renal scar in children with urinary tract infections (UTIs) having primary vesicoureteral reflux (VUR). Data of patients who were examined by dimercaptosuccinic acid (DMSA) scintigraphy between 1995 and 2005 were evaluated retrospectively. Gender, age, reflux grade, presence/development of scarring, breakthrough UTIs, and resolution of reflux, were recorded. The relation of gender, age and VUR grade to preformed scarring and the relation of gender, age, VUR grade, presence of preformed scarring, number of breakthrough UTIs and reflux resolution to new scarring were assessed. There were 138 patients [male/female (M/F) 53/85]. Multivariate analysis showed that male gender [odds ratio (OR) 2.5], age ≥ 27 months in girls (OR 4.2) and grades IV–V reflux (OR 12.4) were independent indicators of renal scarring. On the other hand, only the presence of previous renal scarring was found to be an independent indicator for the development of new renal scar (OR 13.4). In conclusion, while the most predictive variables for the presence of renal scarring among children presenting with a UTI were male gender, age ≥ 27 months in girls, and grades IV–V reflux, the best predictor of new scar formation was presence of previous renal scarring.     

Procalcitonin as a predictor of renal scarring in infants and young children

The aim of this study was to evaluate the usefulness of procalcitonin (PCT) as a marker of renal scars in infants and young children with a first episode of acute pyelonephritis. Children aged 7 days to 36 months admitted for first febrile urinary tract infection (UTI) to a pediatric emergency department were prospectively enrolled. The PCT concentration was determined at admission. Acute ^99mTc-dimercaptosuccinic acid (DMSA) scintigraphy was performed within 7 days of admission and repeated 12 months later when abnormal findings were obtained on the first scan. Of the 72 children enrolled in the study, 52 showed signs of acute pyelonephritis (APN) on the first DMSA scan. A follow-up scintigraphy at the 12-month follow-up performed on 41 patients revealed that 14 (34%) patients had developed renal scars; these patients also presented significantly higher PCT values than those without permanent renal lesions [2.3 (interquartile range 1–11.6) vs. 0.5 (0.2–1.4) ng/mL; p = 0.007]. A comparison of the PCT concentration in patients with febrile UTI without renal involvement, with APN without scar development and with APN with subsequent renal scarring revealed a significant increasing trend (p = 0.006, Kruskal–Wallis test). The area under the ROC curve for scar prediction was 0.74 (95% confidence interval 0.61–0.85), with an optimum statistical cut-off value of 1 ng/mL (sensitivity 78.6%; specificity 63.8%). Based on these results, we suggest that serum PCT concentration at admission is a useful predictive tool of renal scarring in infants and young children with acute pyelonephritis.     

Risk factors for renal scarring in children and adolescents with lower urinary tract dysfunction

Risk factors for renal scarring in children with lower urinary tract dysfunction (LUTD) were evaluated. The medical records of 120 patients were assessed concerning gender, presence of vesicoureteric reflux (VUR), bladder capacity, detrusor overactivity, residual urine, febrile urinary tract infection (UTI), bacteriuria, constipation, detrusor sphincter incoordination (DSI), high detrusor pressure at maximal cystometric capacity (PMCC), low compliance, and thickness and trabeculation of the bladder wall. Renal scarring was diagnosed by ^99mtechnetium-dimercaptosuccinic acid renal scan (DMSA). Renal scarring was detected in 38 patients (31%). VUR, UTI, decreased bladder capacity, urinary residue, and trabeculated and thick bladder wall were associated with scarring at univariate analysis. Multivariate analysis showed VUR (P < 0.0001) as the independent risk factor for renal scarring. Thickness of the bladder wall was a marginal risk factor (P  = 0.07). Although UTI was not a risk factor, it was associated with VUR (P  = 0.03). In our analysis, VUR was the main risk factor; however, renal scarring was probably due to multifactorial causes, as VUR was associated with UTI.     

Genetic susceptibility to renal scar formation after urinary tract infection: a systematic review and meta-analysis of candidate gene polymorphisms

Identifying patients who may develop renal scarring after urinary tract infections (UTI) remains challenging, as clinical determinants explain only a portion of individual risk. An additional factor that likely affects risk is individual genetic variability. We searched for peer-reviewed articles from 1980 to December 2009 in electronic databases that reported results showing an association between gene polymorphims and renal scaring after UTI. Two independent researchers screened articles using predetermined criteria. Studies were assessed for methodological quality using an aggregate scoring system. The 18 studies ultimately included in the review had investigated 16 polymorphisms in nine genes in association with renal scarring formation after UTI. Based on the predetermined criteria for assessing the quality of the studies, 12 studies (67%) were identified as being of poor quality design. A meta-analysis of cumulative studies showed on association between renal scarring formation after UTI and the angiotensin converting enzyme insertion/deletion polymorphism [ACE I/D; recessive model for D allele; odds ratio (OR) 1.73, 95% confidence interval (CI) 1.09–2.74, P = 0.02] or transforming growth factor (TGF)-β1 c.-509 T > C polymorphism (dominant model for T allele; OR 2.24, 95% CI 1.34–3.76, P = 0.002). However, heterogeneity among studies was large, indicating a strong difference that cannot only be explained by differences in study design. The studies reviewed in this article support a modest involvement of the vasomotor and inflammatory genes in the development of renal scarring after UTIs. This review also shows that only few possible candidate genes have been investigated for an association with renal scarring, raising the hypothesis that some gene polymorphisms may exert their effects through an interaction with as yet uninvestigated factors that may be related to geographic and/or socio-economic differences.     

Cholelithiasis following Escherichia coli O157 : H7-associated hemolytic uremic syndrome

Sequelae of Escherichia coli O157 : H7-associated hemolytic uremic syndrome (HUS) 2 – 3 years following an outbreak in Washington State have been prospectively studied to identify predictors of adverse sequelae. Logistic regression analysis was used to examine associations between findings in the acute course and long-term renal and gastrointestinal outcomes. Twenty-one percent of patients had gastrointestinal sequelae, which included cholelithiasis resulting in cholecystectomy (3/29), persistent pancreatitis (2/29), late colon stricture (1/29), and/or glucose intolerance (1/29). Logistic regression analysis found long-term gastrointestinal sequelae were higher in patients who, during HUS, had hypertension [odds ratio (OR) = 21.2, 95% confidence interval (CI) = 1.9 – 164.4, P = 0.01] or gastrointestinal complications (OR = 21.2, 95% CI = 1.9 – 164.4, P = 0.01). Renal sequelae were seen in 35% of patients. One patient (4%) had persistent hypertension and 9 (31%) had minor urinary findings (hematuria or proteinuria). Thrombocytopenia lasting longer than 10 days during the acute illness was associated with a risk for subsequent renal sequelae (OR = 15.0, 95% CI = 1.98 – 1,703.0, P = 0.009). We conclude a high incidence of gastrointestinal sequelae, especially cholelithiasis presenting long after the acute illness, may be seen with HUS. The short follow-up period may underestimate the extent and severity of eventual renal sequelae. Received June 25, 1997; received in revised form October 22, 1997; accepted October 23, 1997     

Comparative clinical outcomes between pediatric and young adult dialysis patients

Published data on the comparative achievement of The Kidney Disease Dialysis Outcome Quality Initative (KDOQI) recommended clinical performance targets between children and young adults on dialysis are scarce. To characterize the achievement of KDOQI targets among children (<18 years) and young adults (18–24 years) with prevalent end stage renal disease (ESRD), we performed a cross-sectional analysis of data collected by the Mid-Atlantic Renal Coalition, in conjunction with the 2007 and 2008 ESRD Clinical Performance Measures Projects. Data on all enrolled pediatric dialysis patients, categorized into three age groups (0–8, 9–12, 13–17 years), and on a random sample of 5% of patients ≥18 years in ESRD Network 5 were examined for two study periods: hemodialysis (HD) data were collected from October to December 2006 and from October to December 2007 and peritoneal dialysis (PD) data were collected from October 2006 to March 2007 and from October 2007 to March 2008. In total, 114 unique patients were enrolled the study, of whom 41.2% (47/114) were on HD and 58.8% (67/114) on PD. Compared to the pediatric patients, young adults were less likely to achieve the KDOQI recommended serum phosphorus levels and serum calcium × phosphorus product values, with less than one-quarter demonstrating values at or below each goal. Multivariate analysis revealed that both young adults and 13- to 17-year-olds were less likely to achieve target values for phosphorus [young adults: odds ratio (OR) 0.04, 95% confidence interval (95% CI) 0.01–0.19, p < 0.001; 13- to 17-year-olds: OR 0.17, 95% CI 0.04–0.77, p = 0.02] and calcium × phosphorus product (young adults: OR 0.01, 95% CI 0.002–0.09, p <  0.001; 13- to 17-year-olds: OR 0.09, 95% CI 0.02–0.56, p = 0.01) than younger children. In summary, there are significant differences in clinical indices between pediatric and young adult ESRD patients.     

Acute kidney injury is independently associated with mortality in very low birthweight infants: a matched case–control analysis

The independent impact of acute kidney injury (AKI) on survival in very low birthweight (VLBW; ≤1,500 g) critically ill infants has not been studied. Cases (non-survivors n = 68) were matched to, at most, two controls (survivors n = 127) by incidence density sampling with replacement, birthweight (± 50 g), gestational age (± 1 week), and availability of serum creatinine (SCr) levels before the index patient’s time of death. Maternal/infant demographic characteristics, co-morbidities, complications and interventions were explored. No difference existed between patients and controls in mean gestational age and birthweight (the matching variables), race, or gender. Compared with the controls, cases had younger mothers, less placental separation, fewer occurrences of hyponatremia, more intra-ventricular hemorrhage, and received chest compressions and cardiac drugs. A 1 mg/dl increase in SCr was associated with almost two-times higher odds of death [odds ratio (OR) = 1.94, 95% confidence interval (95% CI) 1.13–3.32]. OR increased when confounding variables were adjusted (adjusted OR 3.44, 95% CI 1.23–9.61). Similarly, a 100% increase in SCr from trough level was associated with an increased OR = 1.53 (95% CI 1.14–2.04) and became stronger, after adjustment of variables (adjusted OR = 1.90, 95% CI 1.10–3.27). After confounding variables had been controlled for, AKI was independently associated with mortality in VLBW infants. Further prospective multi-center studies are needed to determine whether this association exists.     

TGF-β1 gene polymorphisms and primary vesicoureteral reflux in childhood

The aim of this study was to assess the association between the transforming growth factor-β1 (TGF-β1) gene polymorphisms rs1800469 (commonly known as T-509C) and rs1982073 (commonly known as Leu ¹⁰→Pro) and primary vesicoureteral reflux (VUR) and renal scarring. Using a case–control approach, we examined 121 children with primary VUR and 169 controls. Genotyping of the TGF-β1 gene polymorphisms was performed by restriction fragment length polymorphism (RFLP) analysis. The ^99mTc-DMSA– or ^99mTc-unitiol–single photon emission computed tomography method was used to evaluate renal scars in 84 of 121 VUR children. Statistical analysis revealed differences in rs1800469 genotype frequencies between VUR patients and controls (p = 0.0021). Our data demonstrate that individuals homozygous for the TT genotype are at risk of primary VUR [odds ratio (95% confidence interval) = 2.7 (1.46–5.08)]. Distribution of the rs1982073 polymorphism was similar in VUR children and controls. In terms of renal scarring, patients were stratified into non-scar and scar subgroups, and no differences in the genotype frequencies of either polymorphism was found. Previous reports have shown that the TT genotype of the rs1800469 polymorphism is a risk factor for renal scarring in primary VUR, and the results of our study suggest that this same polymorphism is associated with susceptibility to this congenital uropathy.     

Umbilical Herniorrhapy in Cirrhosis: Improved Outcomes with Elective Repair

Objective This study was undertaken to examine the effect of cirrhosis on elective and emergent umbilical herniorrhapy outcomes. Methods Procedures were identified from the Veterans’ Affairs National Surgical Quality Improvement Program at 16 hospitals. Medical records and operative reports were physician abstracted to obtain preoperative and intraoperative variables. Results Of the 1,421 cases reviewed, 127 (8.9%) had cirrhosis. Cirrhotics were more likely to undergo emergent repair (26.0% vs. 4.8%, p < 0.0001), concomitant bowel resection (8.7% vs. 0.8%, p < 0.0001), return to operating room (7.9% vs. 2.5%, p = 0.0006), and increased postoperative length of stay (4.0 vs. 2.0 days, p = 0.01). Best-fit regression models found cirrhosis was not a significant predictor of postoperative complications. Significant predictors of complications were emergent case (OR 5.4; 95% CI 3.1–9.4), diabetes (OR 2.1; 95% CI 1.2–3.8), congestive heart failure (OR 4.0; 95% CI 1.4–11.4), and chronic obstructive pulmonary disease (OR 2.0; 95% CI 1.1–3.6). Among emergent repairs, cirrhosis (OR 4.4; 95% CI 1.3–14.3) was strongly associated with postoperative complications. Conclusion Elective repair in cirrhotics is associated with similar outcomes as in patients without cirrhosis. Emergent repair in cirrhotics is associated with worse outcomes. Early elective repair may improve the overall outcomes for patients with cirrhosis.     

Acute dialysis-associated peritonitis in children with D+ hemolytic uremic syndrome

Acute peritoneal dialysis (PD) is the preferred therapy for renal replacement in children with post-diarrheal hemolytic uremic syndrome (D+ HUS), but peritonitis remains a frequent complication of this procedure. We reviewed data from 149 patients with D+ HUS who had undergone acute PD with the aim of determining the prevalence and risk factors for the development of peritonitis. A total of 36 patients (24.2%) presented peritonitis. The median onset of peritonitis manifestations was 6 (range 2–18) days after the initiation of dialysis treatment, and Gram-positive microorganisms were the predominant bacterial type isolated (15/36 patients). The patients were divided into two groups: with or without peritonitis, respectively. Univariate analysis revealed that a longer duration of the oligoanuric period, more days of dialysis, catheter replacement, stay in the intensive care unit, and hypoalbuminemia were significantly associated to the development of peritonitis. The multivariate analysis, controlled by duration of PD, identified the following independent risk factors for peritonitis: catheter replacement [p = 0.037, odds ratio (OR) 1.33, 95% confidence interval (CI) 1.02–1.73], stay in intensive care unit (p = 0.0001, OR 2.62, 95% CI 1.65–4.19), and hypoalbuminemia (p = 0.0076, OR 1.45, 95% CI 1.10–1.91). Based on these findings, we conclude that the optimization of the aseptic technique during catheter manipulation and early nutritional support are targets for the prevention of peritonitis, especially in critically ill patients.     

Urinary interleukin-6 is useful in distinguishing between upper and lower urinary tract infections

This study was designed to determine whether the measurement of interleukin (IL)-6 in urine is useful for distinguishing between acute pyelonephritis and lower urinary tract infection. This observational study was carried out at León Hospital (Spain) on 35 patients (ten boys) aged between 0 and 14 years with urinary tract infection. Urinary levels of IL-6 were determined with enzyme-linked immunosorbent assay (ELISA) at diagnosis and after recovery. Renal dimercaptosuccinate acid (DMSA) scan was performed on all patients to discard or confirm acute pyelonephritis. The mean urinary concentration [x ± standard deviation (SD)] of IL-6 at diagnosis was 20.3 ± 23.3 and 5.3 ± 9.7 pg/ml in patients with acute pyelonephritis and lower urinary infection, respectively [95% confidence interval (CI): 2.6–27.4; p < 0.01]. Specificity for a value of IL-6 >15 pg/ml, was 94.1% (95% CI: 91.1–97.1). Positive predictive value for IL-6 >15 pg/ml was 87.5% (95% CI: 81.1–93.8). IL-6 was undetectable in the urine of both groups of patients at the time of recovery. Urinary levels of IL-6 are useful in differentiating between upper and lower urinary tract infection in children. In this clinical setting, a value >15 pg/ml is a strong indicator of acute pyelonephritis.     

Utility of SPECT DMSA renal scanning in the evaluation of children with primary vesicoureteral reflux

OBJECTIVES: DMSA renal scanning is more sensitive than ultrasound in detecting renal parenchymal scars. We proposed to determine the utility of single-photon emission computed tomography (SPECT) dimercaptosuccinic acid (DMSA) renal scanning in children with primary vesicoureteral reflux (VUR). METHODS: During a 24-month period, we evaluated the charts of 368 patients who had undergone SPECT DMSA renal scanning for primary VUR. Patients were divided into three age groups: (a) less than 1 year, (b) between 1 and 5 years, and (c) older than 6 years. Renal scars were deemed severe or focal. The data were analyzed to evaluate the utility of SPECT DMSA scanning in children with primary VUR and to determine the indications for performing SPECT DMSA. We also evaluated the sensitivity of recent renal ultrasound technology in detecting focal and diffuse scars. RESULTS: One hundred twenty-eight patients were younger than 1 year at presentation. These included 24 cases that were detected prenatally. One hundred eighty-five were between the ages of 1 and 5 years, and 55 were 6 years or older. Reflux nephropathy at presentation was found in 99 (26.9%) of 368 patients. DMSA scanning changed the treatment in only 13 patients (3.5%). When scarring was diffuse, ultrasound examination correlated 100% with DMSA scanning; when focal scarring was present, the correlation was poor. CONCLUSIONS: Our results suggest that DMSA scans should be tailored to children who have ultrasound abnormalities, high-grade reflux, or recurrent breakthrough urinary tract infections. These guidelines will result in a substantial cost savings and a significant decrease in radiation exposure.     

EUS-guided versus endoscopic transpapillary gallbladder drainage in high-risk surgical patients with acute cholecystitis: a systematic review and meta-analysis

In patients with acute cholecystitis who are deemed high risk for cholecystectomy, percutaneous cholecystostomy (PC) was historically performed for gallbladder drainage (GBD). There are several limitations associated with PC. Endoscopic GBD [Endoscopic transpapillary GBD (ET-GBD) and EUS-guided GBD (EUS-GBD)] is an alternative to PC. We performed a systematic review and meta-analysis to compare the effectiveness and safety of EUS-GBD versus ET-GBD. We performed a systematic search of multiple databases through May 2019 to identify studies that compared outcomes of EUS-GBD versus ET-GBD in the management of acute cholecystitis in high-risk surgical patients. Pooled odds ratios (OR) of technical success, clinical success and adverse events between EUS-GBD and ET-GBD groups were calculated. Five studies with a total of 857 patients (EUS-GBD vs ET-GBD: 259 vs 598 patients) were included in the analysis. EUS-GBD was associated with higher technical [pooled OR 5.22 (95% CI 2.03–13.44; p = 0.0006; I2 = 20%)] and clinical success [pooled OR 4.16 (95% CI 2.00–8.66; p = 0.0001; I2 = 19%)] compared to ET-GBD. There was no statistically significant difference in the rate of overall adverse events [pooled OR 1.30 (95% CI 0.77–2.22; p = 0.33, I2 = 0%)]. EUS-GBD was associated with lower rate of recurrent cholecystitis [pooled OR 0.33 (95% CI 0.14–0.79; p = 0.01; I2 = 0%)]. There was low heterogeneity in the analyses. EUS-GBD has higher rate of technical and clinical success compared to ET-GBD. While the rates of overall adverse events are statistically similar, EUS-GBD has lower rate of recurrent cholecystitis. Hence, EUS-GBD is preferable to ET-GBD for endoscopic management of acute cholecystitis in select high-risk surgical patients.     

Gender and vesico-ureteral reflux: a multivariate analysis

The aim of this retrospective cohort study was to describe the characteristics of patients with primary vesico-ureteral reflux (VUR) with special attention to gender-specific differences. Between 1970 and 2004, 735 patients were diagnosed with VUR and were systematically followed in a single tertiary renal unit. The following variables were analyzed: race, age at diagnosis, clinical presentation, weight and height Z-score, unilateral/bilateral reflux, VUR grade, renal damage, severity of renal damage, constipation, and dysfunctional voiding. Comparison of proportion between genders was assessed by the chi-square test with Yates’ correction. The logistic regression model was applied to identify independent variables associated with gender. A survival analysis was performed to evaluate VUR resolution. After adjustment, five variables remained independently associated with male gender at baseline: non-white race [Odds ratio (OR) = 1.98, 95% confidence interval (95% CI) 1.33–2.95, P=0.001], moderate/severe grade of reflux (OR=2.16, 95% CI 1.45–3.22, P<0.001), severe renal damage (OR=1.60, 95% CI 1.04–2.52, P=0.04), age at diagnosis <24 months (OR=1.79, 95% CI 1.23–2.60, P=0.002), and antenatal clinical presentation (OR=3.56, 95% CI 1.91–6.63, P<0.001). Follow-up data were available for 684 patients (93%). Median follow-up time was 69 months (range 6 months to 411 months). Girls had a greater risk of urinary tract infection (UTI) during follow-up than boys (OR=1.68, 95% CI 1.18–2.38, P=0.003). There was no difference in progression to chronic renal insufficiency (CRI) between boys (3.8%) and girls (2.4%) during this period of follow-up (OR=1.58, 95% CI 0.59–4.15, P=0.44). Gender as an isolated variable is a poor predictor of clinical outcome in an unselected series of primary reflux. Although boys had a more severe pattern at baseline, girls had a greater risk of dysfunctional voiding and recurrent UTI during follow-up.     

Can prompt treatment of childhood UTI prevent kidney scarring?

The aim of the study reported here was to determine whether kidney scarring after urinary tract infections (UTI) in children can be prevented and to identify the risk factors for developing scars. We identified children in the Northern health region of the UK who had been seen to develop scars, identified as new defects on dimercapto-succinic acid (DMSA) scanning. Risk factors were sought by reviewing case-notes and interviews with parents. Twenty girls were identified whose new scarring was strongly associated with having both vesicoureteric reflux (VUR) and a UTI (p = 0.0001); 19/23 (83%) of kidneys exposed to both of these factors developed scars. Children were much more likely to be febrile (94 vs. 30%, p < 0.0001) or unwell (82 vs. 10%, p < 0.0001) during their earlier UTIs when they were of median age 2.8 years (range 0.3–5.0 years) and did not scar, compared to their later UTIs at age 7.3 years (1.2–12.5 years), when they did scar. However, most patients were treated within 1 day of their symptoms for their early UTIs, compared to a wait ≥7 days for later UTIs (p = 0.001). Being febrile or unwell during a UTI does not predict the development of scars, but prompt treatment appears to prevent scarring in children with VUR.     

Urinary levels of TGF β-1 and of cytokines in patients with prenatally detected nephrouropathies

This study aimed to identify noninvasive biomarkers of clinically significant nephrouropathies in patients with antenatal renal and/or urinary tract alterations. Spot-urine levels of interleukin-6 (IL-6), transforming growth factor-β1 (TGF-β1) and tumor necrosis factor-α (TNF-α) were measured in 100 patients with antenatal detected nephrouropathies. Patients were divided in idiopathic hydronephrosis (n = 47), urinary tract malformations (n = 35), and dysplastic kidneys (n = 18). Urinary concentrations of TGF-β1, IL-6, and TNF-α were compared between groups according to clinical and image findings. Receiver-operating characteristic (ROC) curves were analyzed for the overall diagnostic accuracy of TGF-β1, IL-6, and TNF-α levels in discriminating infants with nephrouropathies. No significant differences in urinary TGF- β1, IL-6, and TNF-α levels were found in the comparison between the groups. TGF-β1 levels tended to be higher in patients with renal hypodysplasia compared to idiopathic hydronephrosis (p = 0.07). Twenty-nine patients had reduced DMSA uptake. In these cases, absolute urinary concentration of TGF-β1 and levels standardized for creatinine were significantly higher than in patients with normal DMSA uptake, while IL6 and TNF-α did not differ between groups. Urinary cytokine measurements were not useful as a screening test for clinically significant nephrouropathies. Conversely, increased concentrations of TGF-β1 pointed out to renal damage as indicated by reduced DMSA uptake.     

Evaluation of activity,chronicity and tubulointerstitial indices for childhood lupus nephritis

Few data exist on use of the National Institutes of Health (NIH) activity index (AI) and chronicity index (CI) in childhood lupus nephritis (LN). A tubulointerstitial activity index (TIAI) has been derived but not validated. We evaluated clinicopathologic correlations of the AI, CI and TIAI in children with LN who had undergone initial renal biopsy (n = 25, age 12.4 ± 2.7 years, biopsy 1) and 1 year after treatment (n = 15, biopsy 2). The TIAI correlated with the AI at biopsy 1 (r = 0.76, P = 0.001) and biopsy 2 (r = 0.52, P = 0.05), but not with CI scores. Mean AI and CI scores changed substantially from biopsy 1 to biopsy 2 (P < 0.05), but TIAI scores did not. Higher AI and TIAI scores correlated with proteinuria at both biopsies (r = 0.51–0.76, P < 0.05); CI scores correlated with estimated creatinine clearance (r = 0.46–0.58, P < 0.05). Improved AI score from biopsy 1 to biopsy 2 was associated with decrease in proteinuria. These results suggest that the AI and CI are useful in childhood LN. The TIAI may be a valid measure to evaluate the tubulointerstitium, but research is needed to define its responsiveness to change with therapy.     

Clinical features of community-acquired <Emphasis Type="Italic">Pseudomonas aeruginosa</Emphasis> urinary tract infections in children

This retrospective chart review sought to determine clinical, radiological, and gender-associated characteristics of community-acquired Pseudomonas aeruginosa (PA) urinary tract infections (UTIs) among children admitted to two medical centers. The records of 73 children with community-acquired PA UTIs were compared with records of 109 children with community-acquired UTIs caused by other pathogens. The mean age of both groups was similar. The PA UTI group included more boys. Features significantly more common in the PA UTI group were the number of patients who had undergone urinary tract surgery, patients with skeletal and/or neurological malformation, patients with >1 previous episode of UTI, patients on prophylactic antibiotic treatment on admission, and patients with pathological renal ultrasound and voiding cystourethrography (VCUG) findings. Multivariate logistic regression analysis revealed the following to be associated with PA UTI: >1 episode of UTI in the past [odds ratio (OR) = 35.5; 95% confidence interval (CI) 11.6–108.7], previous urinary tract surgery (OR = 34.1; 95% CI 7.00–166.2), and pathological VCUG results (OR = 2.62; 95% CI 0.96–7.15). In conclusion, PA UTI is associated with >1 previous UTI, urinary tract abnormalities, and past urinary tract surgery. We recommend that when UTI is suspected in children with these risk factors, a thorough radiologic investigation, including a VCUG, should be considered. Drs. Goldman and Rosenfeld-Yehoshua contributed equally to this work.     

Association between iron overload and osteoporosis in patients with hereditary hemochromatosis

Summary  In 87 patients with hereditary hemochromatosis, osteoporosis was detected in 25%, and osteopenia in 41%. Bone mineral density was independently associated with BMI, ALP levels, hypogonadism/menopause, and the amount of iron removed to reach depletion, but not with cirrhosis. Osteoporosis is influenced by iron overload in hemochromatosis. Introduction  To analyze prevalence, clinical characteristics and genetic background associated with osteoporosis in a retrospective study in Italian patients with hereditary hemochromatosis (HHC). Methods  In 87 consecutive patients with HHC, bone mineral density was systematically evaluated by dual energy x-ray absorptiometry of the lumbar spine (n = 87) and femoral neck (n = 66). Results  Osteoporosis was detected in 22 (25.3%), and osteopenia in 36 (41.4%) patients. Mean Z scores were −0.92 ± 1.42 at lumbar spine and −0.35 ± 1.41 at femoral neck. Lumbar spine T-score was independently associated with total ALP (p = 0.002), hypogonadism/menopause (p = 0.026), and iron overload (p = 0.033 for ferritin and p = 0.017 for iron removed). We observed a borderline significance for BMI (p = 0.069) and smoking status (p = 0.086). Lumbar spine osteoporosis was independently associated with lower BMI (OR 0.73, 95% CI 0.54–0.94), total ALP (OR 1.17, 95% CI 1–1.39 per 10 unit increase) and the amount of iron removed (OR 1.53, 95% CI 1–2.5 per 5 g increase). HFE genotypes did not differ between patients with and without osteoporosis. Conclusions  Osteoporosis is observed in a quarter of unselected patients with HHC, independently of the genetic background, and is associated with ALP, hypogonadism, body weight, and severity of iron overload.     

Serum and urine cystatin C levels in children with post-pyelonephritic renal scarring: a pilot study

Aim We aimed to investigate in children with a history of acute pyelonephritis the influence of unilateral post-pyelonephritic renal scarring detected by DMSA scan on serum (S_CysC) and urine cystatin C (U_CysC) as well as upon other traditional markers of renal damage. Methods Children with DMSA proven pyelonephritis (n = 28) were grouped as either scar [+] (n = 19, unilateral renal scarring) or scar [−] (no scarring, n = 9). The scar [+] group was further divided into scar-1 (differential DMSA uptake, Δ_DMSA ≤ 10%; n = 8) and scar-2 (Δ_DMSA > 10%, n = 11) subgroups. S_CysC, serum creatinine, urine NAG, microalbumin, protein, fractional sodium excretion (FE_Na), tubular phosphate reabsorption (TPR), and U_CysC/Cr were evaluated in all patients. Results Neither S_CysC nor U_CysC were affected by age, height, and weight. scar [+] versus scar [−] groups and scar-1 versus scar-2 subgroups were not different with regard to all studied parameters. S_CysC did not increase in children with post-pyelonephritic unilateral renal scarring. However, 11 children with slightly increased (>0.95 mg/l) S_CysC levels in scar [+] group tended to have higher Δ_DMSA, albeit not significantly. Furthermore, U_CysC/Cr correlated well with urine microalbumin, NAG, and FE_Na in all children and the scar [+] group (P < 0.05). Conclusion S_CysC and U_CysC did not differ among pediatric patients with and without unilateral post-pyelonephritic renal scarring. However, Δ_DMSA uptake between the two kidneys tended to be raised in children with S_CysC levels higher than the reference ranges. Additionally, U_CysC/Cr exhibits parallelism with tubular functions.