Tuberculosis in childhood nephrotic syndrome in India

We studied the prevalence, clinical features, and impact of tuberculosis (TB) on children with nephrotic syndrome (NS). Of the 300 children with NS, 28 (9.3%) were diagnosed as having TB. This occurred following the initiation of immunosuppressive therapy in 27 children, and in 1 child it preceded the onset of NS. Pulmonary involvement was the commonest (22/28), followed by tubercular lymphadenitis (2/28), meningitis (2/28), and occult TB (2/28). Of the various diagnostic criteria, history of previous cough, fever, or exposure to a case of TB (23/28) and chest skiagram (21/28) were the most useful. The occurrence of TB did not induce a relapse or affect the subsequent response to steroid therapy (as is often seen with other infections) or have a deleterious effect on renal function. Patients who received higher doses of steroids (frequent relapsers, steroid dependent, initial non-responders, and subsequent non-responders) had a significantly higher prevalence of TB (19/148) than those who received lower doses (infrequent relapsers 8/151) (P = 0.04). We thus found TB to be an important complication of children with NS in our country. The conventional diagnostic tests, such as Mantoux and acid-fast bacilli isolation, are often unhelpful in these children, and a high index of suspicion is required, especially in children who require frequent courses of steroid therapy. Received March 11, 1996; received in revised form February 27, 1997; accepted March 4, 1997     

The effects of general anesthesia on upper respiratory tract infections in children

A prospective cohort study of 489 pediatric patients was performed to investigate the prevalence of perioperative respiratory complications and symptomatology in children presenting for myringotomy with upper respiratory tract infections (URIs). All children undergoing myringotomy received halothane N2O/O2 anesthesia administered via face mask. Information on complications and respiratory symptoms was obtained from the anesthesia and recovery room records, and by standardized questionnaire. There were no significant differences in perioperative complications between asymptomatic children (1.23%), symptomatic children fulfilling predetermined URI criteria (1.28%), and symptomatic children that did not fulfill the URI criteria (2.38%). In addition, the prevalence and duration of respiratory symptoms was significantly less in children having received anesthesia and surgery than in a matched group of non-anesthetized controls who did not have surgery. Results from this study suggest that there is no increased morbidity for children presenting at minor surgery with acute uncomplicated URIs and who did not require tracheal intubation. In addition, the administration of general anesthesia and surgery to this group of patients was followed by a decrease in both the appearance and duration of a number of respiratory symptoms.     

Short term follow up of childhood focal segmental glomerulosclerosis in India

Summary: A retrospective analysis of 67 biopsy proven cases of focal segmental glomerulosclerosis (FSGS) in children was performed. After a mean duration of disease of 48.5 ± 44 months, 20 patients (30%) achieved sustained remission (SR), 23 (34%) had frequent relapses (FR) and 24 (36%) were steroid non-responders (NR). the NR group had a significantly higher mean age of onset 9.1 ± 1.01 years ( P = 0.003) and had higher number of females ( P = 0.0009). They also had a significantly higher prevalence of microhaematuria as compared to FR and SR groups ( P = 0.002). the initial steroid response category ( P <0.00001) and the percentage of glomeruli with segmental sclerosis on histopathology ( P = 0.001) correlated with the subsequent outcome. During this period six children developed progressive renal failure and all of them belonged to NR group (25%). There were four deaths and all of them were non-responders (16.6%). Features predictive of a poor therapeutic outcome in childhood FSGS are age of onset more than 9 years, female sex, microhaematuria, renal dysfunction at onset, initial non-response to steroids and percentage of glomeruli with segmental sclerosis on histopathology.     

Serum zinc in critically ill adult patients with acute respiratory failure

Background and aims: Zinc deficiency leads to susceptibility to infections and may affect pulmonary epithelial cell integrity. Low zinc levels have also been associated with a degree of organ failure and decreased survival in critically ill children. Accordingly, the purpose of the study was to assess serum zinc in adult patients with acute respiratory failure, its association with ventilatory support time, intensive care unit (ICU) length of stay (LOS), organ dysfunction and 30‐day mortality. Methods: We included consecutive patients with acute respiratory failure during an eight‐week prospective, observational multicentre study (the FINNALI‐study). Acute respiratory failure was defined as a need for either non‐invasive or invasive positive pressure ventilation for >6 h regardless of the underlying cause or risk factors. After informed consent, a sample for zinc measurement was drawn at 6 h after the start of treatment and analysed from 551 of these patients. Results: Low serum zinc was frequent (95.8%) at the onset acute respiratory failure. The median interquartile range [IQR] was 4.7 [3.0–6.9] μmol/l. The median [IQR] serum zinc levels in non‐infectious, sepsis and septic shock patients were 5.0 [3.1–7.1], 5.1 [3.5–7.3] and 3.8 [2.6–5.9] μmol/l, respectively, P<0.01. Baseline zinc levels were not associated with ventilatory support time (P=0.98) or ICU LOS (P=0.053). The area under curve in receiver operating characteristics analysis for serum zinc regarding 30‐day mortality was 0.55 (95% CI 0.49–0.60). Conclusions: Serum zinc on initiation of ventilation had no predictive value for 30‐day mortality, ventilatory support time or intensive care unit LOS.     

糖尿病伴感染性疾病与体质指数的相关性及其危险因素

目的探讨体质指数与糖尿病伴感染性疾病的相关性以及糖尿病伴感染性疾病的危险因素。 方法用病例-对照研究方法分析长沙市中心医院2012年5月至2014年5月收治的590例糖尿病伴感染性疾病患者（观察组）和610例未合并感染性疾病的糖尿病患者（对照组）的体质指数（BMI）,通过Logistic回归分析进行危险因素的多因素分析。 结果观察组患者体质指数低于对照组（t = 6.687、P < 0.001）;按BMI进行分层,两组患者分布差异有统计学意义（χ² = 50.128、P < 0.001）。观察组患者以下呼吸道感染为主（占65.7%）,其次为消化道感染（11.59%）、泌尿道感染（9.05%）、上呼吸道感染（7.78%）、皮肤（3.33%）以及其他部位感染（2.53%）。Logistic回归分析显示,体质指数升高是糖尿病伴感染性疾病的保护因素（OR = 0.778,95%CI：0.648～0.934）;而年龄增长、伴慢性阻塞性肺病和肝硬化是糖尿病伴感染性疾病的危险因素（OR = 1.614,95%CI：1.365～1.908;OR = 3.076,95%CI：1.745～5.424;OR = 6.717,95%CI：0.740～60.951）,但肝硬化作为危险因素在回归方程中无统计学意义。 结论糖尿病伴感染性疾病与体质指数相关,但需要进一步细化分析其作用;糖尿病患者特别是高龄及合并慢性阻塞性肺病、肝硬化的患者应特别注意感染性疾病的发生。     

Clinical features of children with anti-CFH autoantibody-associated hemolytic uremic syndrome: a report of 8 cases

ObjectiveTo explore the clinical characteristics, treatment protocol and prognosis of children with anti-complement factor H (CFH) autoantibody (Ab)-associated hemolytic uremic syndrome (HUS).MethodsClinical data of 8 patients with anti-CFH Ab-associated HUS who were admitted to Shandong Provincial Hospital from January 2011 to December 2020 were collected retrospectively.ResultsThe age at disease onset ranged between 5.83 and 13.5 years, with a male: female ratio of 1.67:1. The time of onset was distributed from May to June and November to December. Digestive and upper respiratory tract infections were common prodromal infections. Positivity for anti-CFH Ab and reduced C3 levels were observed among all patients. Heterozygous mutation of the CHFR5 gene (c.669del A) and homozygous loss of the CFHR1 gene [loss2(EXON:2-6)] were found in two patients. All patients received early treatment with plasma exchange and corticosteroid therapy. Six patients were given immunosuppressive agents (cyclophosphamide and/or mycophenolate mofetil) for persistent proteinuria. The follow-up period was 12–114 months. Four of 8 patients achieved complete remission, 3 achieved partial remission, and 1 died. Relapse occurred in two patients.ConclusionChildren with anti-CFH Ab-associated HUS were mainly school-aged and predominantly male, with onset times of summer and winter. Digestive and upper respiratory tract infections were common prodromal infections. Plasma exchange combined with methylprednisolone pulse therapy in the acute phase and cyclophosphamide or mycophenolate mofetil treatment for maintenance can be utilized in children with anti-CFH Ab-associated HUS if eculizumab is not available.     

Risk factors for steroid dependency in children with idiopathic nephrotic syndrome

Minimal change disease, the most common cause of idiopathic nephrotic syndrome (INS) in children, has a high relapse rate, with approximately half of patients developing steroid dependency. This study was aimed at determining the predictive risk factors for the development of steroid dependency in children diagnosed with INS. A retrospective study of 123 children with steroid-responsive INS, followed for at least 6 months between December 1974 and December 1999, was conducted. The following parameters were studied as predictors of steroid dependency: age at onset, gender, race, microscopic hematuria at onset, atopy, concomitant upper respiratory tract infections (URTI) during relapses, and days to remission with initial steroid therapy. Of the 91 children who fulfilled the inclusion criteria, 61.5% became steroid dependent. Both univariate and logistic regression analyses revealed that initial remission time of 9 or more days (P=0.02, OR=3.0, 95% CI=1.2–7.9) and concomitant URTI during relapses (P=0.01, OR=3.4, 95% CI=1.3–8.8) were significant predictors of steroid dependency. By identifying those children with predictive factors of steroid dependency, the clinician will be better able to plan the long-term management of these patients and reduce the morbidity seen with the frequent relapses and steroid treatment, in a disease that is otherwise associated with a favorable prognosis. Received: 4 October 2000 / Revised: 27 August 2001 / Accepted: 28 August 2001     

Nosocomial infections in infants and children after cardiac surgery

Objective  To identify the incidence, characteristics and risk factors of nosocomial infections (NIs) in infants and children undergoing open heart surgery, a prospective observational study. Methods  One hundred consecutive infants and children < 2 yrs of age undergoing open heart surgery (OHS) between March 2007 and December 2007 were included in the study. Samples for blood, endotracheal and urine culture were drawn daily during intensive care unit (ICU) stay. Cultures from endotracheal tube, central venous catheter, arterial cannula, chest tube, urinary catheter and other invasive lines were also obtained. Centers for Disease Control and Prevention criteria were used for defining NIs. A number of possible risk factors predisposing to NI were analyzed. Results  32% patients developed NI. The NI rate was 49%. Common NIs were bloodstream infection (19%), respiratory tract infection (17%), catheter site infection (7%) and urinary tract infection (6%). Common pathogens were Acinetobacter (22.5%), Pseudomonas aeruginosa (20.4%), Klebsiella pneumoniae (16.3%) and Staphylococcus aureus (12.2%). Major risk factors for NI were length of ICU stay (p < 0.001), duration of intubation (p < 0.001), reintubation (p < 0.001), duration of central venous catheterization (p = 0.001), preoperative congestive heart failure (p = 0.002), tracheostomy (p = 0.003), duration of preoperative stay (p = 0.01), blood transfusion (p = 0.01), preoperative balloon atrial septostomy (p = 0.02), duration of surgery (p = 0.03), surgical complexity score (p = 0.03) and hypothermia (p = 0.03). The mortality rate was 11% with significant association between NI and death (p = 0.002). Conclusion  NIs develop frequently in infants and children after OHS. This study may serve as a reference point for further development and implementation of interventions aimed at reducing NI rates and improving patient outcome.     

Epidemiology and Immediate Indirect Effects of Respiratory Viruses in Lung Transplant Recipients: A 5‐Year Prospective Study

The epidemiology of respiratory viruses (RVs) in lung transplant recipients (LTRs) and the relationship of RVs to lung function, acute rejection (AR) and opportunistic infections in these patients are not well known. We performed a prospective cohort study (2009–2014) by collecting nasopharyngeal swabs (NPSs) from asymptomatic LTRs during seasonal changes and from LTRs with upper respiratory tract infectious disease (URTID), lower respiratory tract infectious disease (LRTID) and AR. NPSs were analyzed by multiplex polymerase chain reaction. Overall, 1094 NPSs were collected from 98 patients with a 23.6% positivity rate and mean follow‐up of 3.4 years (interquartile range 2.5–4.0 years). Approximately half of URTIDs (47 of 97, 48.5%) and tracheobronchitis cases (22 of 56, 39.3%) were caused by picornavirus, whereas pneumonia was caused mainly by paramyxovirus (four of nine, 44.4%) and influenza (two of nine, 22.2%). In LTRs with LRTID, lung function changed significantly at 1 mo (p = 0.03) and 3 mo (p = 0.04). In a nested case–control analysis, AR was associated with RVs (hazard ratio [HR] 6.54), Pseudomonas aeruginosa was associated with LRTID (HR 8.54), and cytomegalovirus (CMV) replication or disease was associated with URTID (HR 2.53) in the previous 3 mo. There was no association between RVs and Aspergillus spp. colonization or infection (HR 0.71). In conclusion, we documented a high incidence of RV infections in LTRs. LRTID produced significant lung function abnormalities. Associations were observed between AR and RVs, between P. aeruginosa colonization or infection and LRTID, and between CMV replication or disease and URTID.     

Oxidant stress in primary nephrotic syndrome: does it modulate the response to corticosteroids?

In order to assess the oxidative stress in newly diagnosed children with primary nephrotic syndrome (PNS), we serially measured serum total antioxidant capacity (TAC) and malondialdehyde (MDA) in 33 children with PNS and ten healthy matched controls. Patients were classified into two groups: those who had steroid-sensitive nephrotic syndrome (SSNS; n = 26) and those who had steroid-resistant nephrotic syndrome (SRNS; n = 7). Of the patients with SSNS, 15 were non-relapsers and 11 were relapsers. At the proteinuric phase, all patients had significantly higher MDA levels and lower TAC than the controls. These changes were more marked in patients with SRNS than in those with SSNS. During remission and still on corticosteroids, patients had higher TAC and similar MDA levels as in the proteinuric phase, but the TAC and MDA levels still significantly differed from those of the controls. More improvement in TAC and MDA levels occurred in patients following the weaning of corticosteroids, but TAC was still lower in the patients than in the controls. Moreover, TAC was higher in non-relapsers than in relapsers. Using a receiver operating characteristic curve, the initial response to corticosteroids could be predicted at serum TAC level ≥0.73 mM/L (sensitivity 89%, specificity 86%), while serum TAC levels ≤ 1.14 mM/L after the weaning of corticosteroids could predict that the patient would not relapse (sensitivity 91%, specificity 80%). In conclusion, based on our results, PNS can be considered to be associated with oxidative stress even during remission. This stress may modulate the response to corticosteroids. Further prospective studies using larger numbers of patients are needed to validate these results.     

Serum zinc and copper levels in children with chronic renal failure

We evaluated changes in serum zinc (Zn) and copper (Cu) levels in two groups of children with chronic renal failure (CRF) – children with CRF who were on regular hemodialysis (Group 1, n=40) and children with CRF who were on conservative management (Group 2, n=31) – and in one group of healthy children (Group 3, n=30). All of the participants in the study were between 5–18 years old, and the composition of the three groups was almost identical with respect to age and sex. The length of time the children in Group 1 had been on hemodialysis varied between 3 and 52 months (mean: 20.97±14.8 months). To evaluate the impact of the duration of dialysis on serum levels of Zn, we further sub-divided Group 1 patients into two subgroups: Subgroup A patients (n=20) had been on hemodialysis therapy for less than 18 months (mean: 8.85±4.83 months); Subgroup B patients (n=20) had been on hemodialysis therapy for longer than 18 months (mean: 33.1±10.86 months). The PIXE (proton-induced X-ray emission) was used for measuring the trace elements. Results: The mean serum level of Zn was lower in the Group 1 (hemodialysis group) children than in the children of Group 2 (on conservative management) and group 3 (healthy children) (p<0.001), but the difference was not significant between Groups 2 and 3. No significant differences in serum levels of Cu were found among the three groups. The serum level of Zn was lower in Subgroup B than in Subgroup A (p<0.001). The correlation test showed that there was an inverse linear relation between the length of time the child was on the hemodialysis regimen and serum Zn levels. Conclusion: Chronic hemodialysis may lead to abnormalities in the serum levels of some trace elements in children with CRF that increase in severity with increasing duration of hemodialysis. Deficiencies of these trace elements – zinc in particular – may contribute to various conditions and symptoms in children undergoing chronic hemodialysis.     

Infections in pediatric kidney and liver transplant patients after perioperative hospitalization

BACKGROUND: Infectious complications are a major cause of morbidity and mortality after organ transplantation. There are several reports on infections during the first months after transplantation, but there are very few data regarding infections in long-term survivors of pediatric organ transplantation. METHODS: The incidence and type of infections were retrospectively analyzed in 56 children who underwent 59 liver or renal transplantations. Follow-up was begun when the patient was sent home after a successful operation. All of the children received triple immunosuppression. RESULTS: During a mean follow-up of 4.8 years (total, 286 patient years), 1540 episodes of infection were recorded. The median incidence was 4.8 episodes/patient year. The greatest number was seen in the smallest children, 3 to 6 months after transplantation. Viral upper respiratory tract infections were the most common problem, accounting for half of the episodes (2.7 episodes/patient year). Gastroenteritis was the second most common viral infection. Only 45 episodes of infection with herpesviruses were recorded, and seven of those were caused by cytomegalovirus. Otitis media and sinusitis were the most common bacterial infections and complicated upper respiratory infection in 23% of episodes. Thirty-nine episodes of urinary tract infections were diagnosed, thirty-one in children with renal transplants. Other bacterial infections were rare, and only three episodes of verified bacterial sepsis were diagnosed. CONCLUSION: The frequency and type of infections in children with liver and renal transplants who are on triple immunosuppression are quite similar to those in age-matched healthy children.     

Diagnostic value of the pediatric lower urinary tract symptom score in children with overactive bladder

Purpose

The aims were (1) to assess the pediatric lower urinary tract symptom score (SS) prior to treatment as a means of determining severity of overactive bladder (OAB) and (2) to investigate relationships between SS results and those of standard diagnostic modalities.

Materials and methods

Symptom scores were recorded pre- and 6 months SS for 294 children with OAB unrelated to neurological disorder. Uroflowmetry–electromyography data, total bladder capacity, and a 2-day bladder diary were also recorded, and upper urinary tract deterioration was investigated as indicated. Overactive bladder was treated with standard approaches. No response to treatment was defined as 0–49 % reduction in OAB-related symptoms based on SS results. Non-responders underwent additional evaluations as indicated.

Results

Two hundred forty-one patients (97 %; mean age 9.8 ± 2.8 years; mean follow-up 11 months; range 6–18 months) completed the study. One hundred thirteen (47 %) required ultrasonography (USG), and those with abnormal USG had a significantly higher pre- and 6 months SS (p = 0.016). All non-responders (n = 38; 16 %) underwent urodynamics evaluation, 34 underwent spinal magnetic resonance imaging (MRI), 34 underwent voiding cystourethrography (VCUG), and 34 underwent dimercaptosuccinic acid scanning (DMSA). Non-responders with terminal detrusor hyperactivity had significantly lower SS after therapy (p = 0.09). Non-responders with abnormal MRI had higher pre- and 6 months SS than those with normal MRI. Thirteen (38 %) of the non-responders who required VCUG had vesicoureteral reflux (VUR), and this subgroup had higher pre-treatment SS (p = 0.030). Seven (21 %) of the non-responders who required DMSA had scarring, and all 7 had VUR. The subgroup with scarring had higher pre-treatment SS (p = 0.030).

Conclusion

Pediatric OAB patients with high 6 months SS have a higher incidence of additional upper urinary tract pathology. Those with low pre-treatment SS require fewer laboratory tests and other assessments. The SS tool can reduce the number of urodynamics evaluations, and other tests required to diagnose renal damage in children with OAB.     

Racial differences in the incidence and renal outcome of idiopathic focal segmental glomerulosclerosis in children

The North American Pediatric Registry reports that from 1987 to 1989 blacks and Hispanic children accounted for 23% of all renal transplants performed but 38% of those performed for focal segmental glomerulosclerosis (FSGS). From these data, we infer that blacks and Hispanics form a disproportionate number of FSGS patients who progress to end-stage renal disease (ESRD) compared with white children. To explore this hypothesis we assessed our single-center experience of FSGS comparing black and Hispanic with white children. Of 177 black and Hispanic children followed in our clinic for idiopathic nephrotic syndrome (NS) between 1974 and 1989, 57 were diagnosed as having FSGS (group I). The mean age at onset of NS of these group I patients was 7.3±4.6 years and the mean duration of follow-up was 8.25±4.3 years. During the same period, 13 of 65 white patients (group II) with idiopathic NS were found to have FSGS. Their mean age (7.8±4.8 years) and duration of follow-up (8.8±4.8 years) were similar. Therapeutic modalities in the two groups were also similar. Of group I patients, 78% (42/54) reached ESRD compared with 33% (4/12) of group II patients (P<0.01). Life table analysis showed that 50% of black and Hispanic children will reach ESRD within 3 years of FSGS. In a subset of patients, multiple regression analysis revealed that the higher the serum creatinine at the onset of NS (P<0.01,r=0.519), and the higher the serum cholesterol at the onset of NS (P<0.02,r=0.511), the more rapid the progression to ESRD. Based on our findings, a national survey to determine if FSGS is more virulent in black and Hispanic children is warranted.Presented in part at the 22nd Annual Meeting of the American Society of Nephrology, Washington, D. C., December 1989     

Early postoperative complications of pediatric liver transplantation: experience at one center

To evaluate the postoperative complications within the first month among 20 pediatric liver transplant recipients between April 1990 and March 2003 we retrospectively studied their medical charts to gather demographic data; primary diagnosis; operative duration; perioperative transfusions; time to extubation; length of intensive care unit (ICU) stay; mortality; perioperative laboratory values; and postoperative complications including respiratory, infections, renal, neurological, cardiovascular, and gastrointestinal tract (GIT) complications. Ten male and ten female patients of mean age 8 +/- 4 years had a mean operative duration, time to extubation, and length of stay in the ICU of 12.1 +/- 2.3 hours, 11.1 +/- 15.0 hours, and 7.2 +/- 5.5 days, respectively. The most frequent postoperative complication was respiratory (n = 14, 70%), followed by infections (n = 13, 65%), renal (n = 8, 40%), neurological (n = 7, 35%), cardiovascular (n = 4, 20%), and GIT (n = 4, 20%) infections. The overall mortality rate was 25% (n = 5). Compared with patients who survived, those who died displayed significantly lower perioperative platelet counts (P <.05), as well as a significantly higher incidence of postoperative neurological disorders (P =.031), and cardiovascular complications (P =.032).     

Surveillance of Bacterial and Fungal Infections in the Postoperative Period Following Liver Transplantation: A Series From 2005–2011

Orthotopic liver transplantation (OLT) is a life-saving procedure for the treatment of many end-stage diseases, but infectious and acute rejection episodes remain major causes of morbidity and mortality. Bacterial and fungal infections can be due to intra-abdominal, biliary, respiratory, urinary, wound, central venous catheters (CVC) or unknown sources. Using the computerized database of our microbiology laboratory, we analyzed all the bacterial and fungal infections in the first three months following OLT among 151 consecutive adult recipients at single center between January 2005 and December 2011. Samples included blood, bile CVC, urine, and bronchoalveolar lavage (BAL) specimen. Culture and identification of the isolated microorganisms was done in accordance with standard microbiological procedures. Three hundred thirteen samples from the above sites showed positive results for gram-positive cocci (n = 137; 43.8%), gram-negative rods (n = 156; 49.8%), and Candida species (n = 19; 6.1%). One patient (0.3%) experienced a CVC-related infection caused by Fusarium oxysporum. Bacterial and particularly biliary tract infections seem to play major roles in morbidity and mortality in the first three months following OLT. The major contributors to patient morbidity and mortality were candidemia and/or invasive candidiasis mainly from the biliary tract and/or CVC-related infections.     

Urinary tract infections in children with posterior urethral valves after kidney transplantation.

The records of 14 boys with posterior urethral valves who had renal failure and subsequently underwent renal transplantation were reviewed to determine the postoperative incidence of urinary tract infection relative to that of 29 male transplant children without valves, who served as controls. There were no significant differences between the posterior urethral valve patients and controls with regard to age, donor source, immunosuppression, followup after transplantation or mean calculated creatinine clearance. Vesicoureteral reflux was found in 1 child with posterior urethral valves and 3 of the children in the control group (p not significant). A total of 15 urinary tract infections occurred in 5 children (36%) with posterior urethral valves, for a rate of 1 per 30 patient-months of followup, and 6 urinary tract infections occurred in 2 controls (7%), for a rate of 1 per 216 patient-months of followup (p < 0.05). However, only 1 of 26 controls (4%) without vesicoureteral reflux had urinary tract infection, for a rate 1 per 1,144 patient-months (p < 0.01). Conversely, the rate of urinary tract infections in controls with vesicoureteral reflux was similar to that of children with posterior urethral valves. Of the 5 children with posterior urethral valves 4 had the initial urinary tract infection within 2 months of transplantation and 10 of 15 episodes occurred within the first 4 months. Antimicrobial prophylaxis did not appear to decrease the rate of infection in children with posterior urethral valves. A history of posterior urethral valves increases the frequency of urinary tract infection after renal transplantation but the usefulness of antimicrobial prophylaxis and the relationship to long-term graft function remain to be determined. Urinary tract infection rarely develops in other transplanted boys without vesicoureteral reflux.     

Pulse cyclophosphamide therapy in frequently relapsing nephrotic syndrome.

BACKGROUND: The treatment of frequently relapsing (FR) and steroid-dependent (SD) idiopathic nephrotic syndrome (INS) with oral cyclophosphamide (OCP) poses problems of compliance, side-effects and infections. METHODS: We prospectively evaluated the usefulness of intravenous cyclophosphamide (IVCP) in children with steroid sensitive INS who were frequent relapsers or steroid dependent. Fifty-one children were included in the study of whom 22 were FR and 29 were SD. IVCP was administered in a dose of 500 mg/m(2)/month for 6 months after achieving a steroid-induced remission. The response to IVCP was evaluated in terms of remission, change in the steroid response status of the patient, duration of remission (i.e. proteinuria-free days), side effects and compliance with therapy. RESULTS: The proteinuria-free days (mean 19.9+/-3.5 before IVCP therapy vs 1256+/-167 days after IVCP therapy) (P<0.00001), and serum albumin levels (23+/-1.6 g/l before IVCP therapy vs 34+/-2 g/l after IVCP therapy) (P<0.001) were significantly higher following IVCP therapy. The cumulative remission rate in the study group was 49% at 5 years and was comparable to that achieved with oral cyclophosphamide at a 40% lower cumulative dose. CONCLUSIONS: We conclude that IVCP is a safe and effective therapeutic modality in children with INS who are FR and SD. Its efficacy is comparable to the results obtained with oral cyclophosphamide based on historical comparisons with previous studies.     

Risk Factors for Adverse Postoperative Outcomes in Children Presenting for Cardiac Surgery with Upper Respiratory Tract Infections

Background: Otherwise healthy children who present for elective surgery with an upper respiratory infection (URI) may be at risk for perioperative respiratory complications. This risk may be increased in children with congenital heart disease who undergo cardiac surgery while harboring a URI because of their compromised cardiopulmonary status. Therefore, this study was designed to determine the incidence of peri- and postoperative complications in children undergoing cardiac surgery while harboring a URI.

Methods: The study population consisted of 713 children scheduled to undergo cardiac surgery. Of these, 96 had symptoms of URI, and 617 were asymptomatic. Children were followed prospectively from induction of anesthesia to discharge from the hospital to determine the incidence of postoperative respiratory, cardiovascular, neurologic, and surgical adverse events. Duration of postoperative ventilation, time in the intensive care unit (ICU), and length of hospital stay were also recorded.

Results: Children with URIs had a significantly higher incidence of respiratory and multiple postoperative complications than children with no URIs (29.2 vs. 17.3% and 25 vs. 10.3%, respectively;P < 0.01) and a higher incidence of postoperative bacterial infections (5.2 vs. 1.0%;P = 0.01). Furthermore, logistic regression indicated that the presence of a URI was an independent risk factor for multiple postoperative complications and postoperative infections in children undergoing open heart surgery. Children with URIs also stayed longer in the intensive care unit than children with no URIs (75.9 +/- 89.8 h vs. 57.7 +/- 63.8, respectively;P < 0.01). However, the overall length of hospital stay was not significantly different (8.4 vs. 7.8 days, URI vs. non-URI groups;P > 0.05).     

Renal transplantation following renal failure due to urological disorders

Background. Renal allograft outcome, during an 8 year period (1985-1992), has been assessed in 56 renal transplants performed in 55 patients who had end-stage renal failure as a consequence of urological abnormalities. The abnormalities were: primary vesicoureteric reflux (VUR) or renal dysplasia (26 patients); posterior urethral valves (PUV) (15); neuropathic bladders (6); vesico-ureteric tuberculosis (5); bladder exstrophy (3); and prune belly syndrome (1). Six patients had augmented bladders, and eight transplants were performed in seven patients with urinary diversions. Results. Overall, 1 and 5 year actuarial graft survival was 89 and 66%, with mean creatinine of 154 &mgr;mol/l ± 11 (SE) and 145 ± 9 respectively. Patients with abnormal bladders or conduits (n = 28) had worse graft function than those with normal bladders (n = 28) although graft survival was not significantly different in the two groups at 1 and 5 years: 93 and 75% with normal bladders vs 86 and 57% with abnormal systems. Symptomatic urinary tract infections were common in the first 3 months after transplantation (63%); fever and systemic symptoms occurred in 39% with normal bladders and 59% with abnormal bladders. Urinary tract infection directly contributed to graft loss in six patients with abnormal bladders, but had no consequences in those with normal bladders. Conclusions. Abnormal bladders must be assessed urodynamically before transplantation, and after transplantation adequacy of urinary drainage must be re-assessed frequently. Prophylactic antibodies are now given for the first 6 months and urinary tract infections must be treated promptly. With these measures, good results, similar to those of patients without urological problems, can be obtained.