Determining the Bulk of the Iceberg of Proteinuric Chronic Kidney Disease in School Children, in South West Nigeria

Introduction: Chronic kidney disease [CKD], as defined by the National Kidney Foundation/Kidney Disease and Outcome Quality Initiative (KDOQI) Group, refers to bilateral kidney injury and/or impaired kidney function of at least 3 months duration. Persistent proteinuria has been recognized as one of the early markers of chronic kidney disease and has been associated with persistent and progressive damage in both children and adult. This study was conducted with the aim of determining the prevalence and severity of persistent proteinuria over three months in primary school children in Ile-Ife. It was a cross-sectional study done over a period of six months. The subjects were 1335 primary school pupils, aged 6 to 14 years selected by multi stage random sampling method from twelve primary schools from a total of 96,301 pupils in the two Local Government Areas (LGA) of Ile-Ife, after meeting the recruitment criteria. The biodata, physical examination, blood pressure measurements and urine testing by dipstick were carried out on all the recruited pupils according to standard protocols while serial monitoring of proteinuria and estimated glomerular filtration rate was done for those with persistent proteinuria over 6 months. Results: Initially 34 (2.6%) of the subjects recruited had significant proteinuria with a M:F ratio of 1:1.6 following first screening and it was persistent in six (0.4%) of them subsequently over three months with a M:F ratio of 1:1.5. The severity of the persistent proteinuria was in the range of 30 mg/dL to 100 mg/dL. Three of them (50%) had worsened level of proteinuria from 30 mg/dL to 100 mg/dl on follow up. Conclusion: Children with undetected persistent proteinuria stand the risk of further glomerular damage over time.

Management of nocturnal enuresis-myths and facts

Nocturnal enuresis often causes considerable distress or functional impairment to patient and their parents necessitating a multidisciplinary approach from paediatrician, paediatric nephrologist, urologists and psychiatrist. Mechanisms of monosymptomatic nocturnal enuresis are mainly nocturnal polyuria, bladder overactivity and failure to awaken from sleep in response to bladder sensations. Goal oriented and etiology wise treatment includes simple behavioral intervention, conditioning alarm regimen and pharmacotherapy with desmopressin, imipramine and anticholinergic drugs. Symptoms often recurs requiring change over or combination of different modes of treatment.

Epidemiology, pathophysiology, clinical characteristics and management of childhood cardiorenal syndrome

Cardiorenal syndrome(CRS) is a new term recently introduced to describe the acute or chronic comorbid state of the heart and kidney that has been long known and frequently managed in very sick individuals. The tight and delicate coordination of physiological functions among organ systems in the human body makes dysfunction in one to lead to malfunction of one or more other organ systems. CRS is a universal very common morbidity in the critically ill, with a high mortality rate that has received very little research attention in children. Simultaneous management of heart and renal failures in CRS is quite challenging; the therapeutic choice made for one organ must not jeopardize the other. This paper reviews the epidemiology, pathophysiology, clinical characteristics and management of acute and chronic CRS in children.

Pre-treatment considerations in childhood hypertension due to chronic kidney disease

Hypertension （HTN） develops very early in childhood chronic kidney disease （CKD）. It is linked with rapid progression of kidney disease, increased morbidity and mortality hence the imperative to start anti-hypertensive medication when blood pressure （BP）is persistently 〉 90th percentile for age, gender, and height in non-dialyzing hypertensive children with CKD. HTN pathomechanism in CKD is multifactorial and complexly interwoven. The patient with CKD-associated HTN needs to be carefully evaluated for co-morbidities that frequently alter the course of the disease as successful treatment of HTN in CKD goes beyond life style modification and anti-hypertensive therapy alone. Chronic anaemia, volume overload, endothelial dysfunction, arterial media calcifcation, and metabolic derangements like secondary hyperparathyroidism, hyperphosphataemia, and calcitriol deficiency are a few co-morbidities that may cause or worsen HTN in CKD. It is important to know if the HTN is caused or made worse by the toxic effects of medications like erythropoietin, cyclosporine, tacrolimus, corticosteroids and non-steroidal anti-infammatory drugs. Poor treatment response may be due to any of these co-morbidities and medications. A satisfactory hypertensive CKD outcome, therefore, depends very much on identifying and managing these co-morbid conditions and HTN promoting medications promptly and appropriately. This review attempts to point attention to factors that may affect successful treatment of the hypertensive CKD child and how to attain the desired therapeutic BP target.

Post-transplantation lymphoproliferative disorders:Current concepts and future therapeutic approaches

Transplant recipients are vulnerable to a higher risk of malignancy after solid organ transplantation and allogeneic hematopoietic stem-cell transplant.Posttransplant lymphoproliferative disorders(PTLD)include a wide spectrum of diseases ranging from benign proliferation of lymphoid tissues to frank malignancy with aggressive behavior.Two main risk factors of PTLD are:Firstly,the cumulative immunosuppressive burden,and secondly,the oncogenic impact of the Epstein-Barr virus.The latter is a key pathognomonic driver of PTLD evolution.Over the last two decades,a considerable progress has been made in diagnosis and therapy of PTLD.The treatment of PTLD includes reduction of immunosuppression,rituximab therapy,either isolated or in combination with other chemotherapeutic agents,adoptive therapy,surgical intervention,antiviral therapy and radiotherapy.In this review we shall discuss the prevalence,clinical clues,prophylactic measures as well as the current and future therapeutic strategies of this devastating disorder.

Functional constipation in Bangladeshi school aged children:A hidden misty at community

BACKGROUND Constipation is a common problem in children and a frequent cause of hospital visit in both primary&specialized care,which needs proper evaluation&management.Presentation of constipation is variable among children.In Bangladesh there has been no published data regarding constipation in community among school aged children.AIM To determine the magnitude of functional constipation and its risk factors in community among Bangladeshi school children.METHODS This descriptive cross sectional study was conducted in different schools of Dhaka division,Bangladesh.All school aged children between 5-16 years of age who attended school were included in this study.Samples were collected randomly.Proper clinical history&physical examinations(without digital rectal examination)&available investigations(if done previously)were recorded.Diagnosis of functional constipation was done by Rome IV criteria and was compared with children without constipation.Children with any red flag sign,known chronic disease or any findings suggestive of organic disease and on treatment of constipation were excluded.Statistical analysis of the results was done by using Windows based software device with Statistical Packages for Social Science 20.For all statistical tests,P value of less than 0.05 was considered as statistically significant.RESULTS Total study populations were 707 and male was 443 and female 264.Among them,134(19%)children had constipation.In constipated children,78 children fulfilled the Rome IV criteria for functional constipation and it was 11%of total population.Mean age of children having functional constipation was 11.24±3.54 years and Male female ratio was 1:1.78.Anorexia,nausea,abdominal pain,hard stool,blood with hard stool,alternate hard and loose stool and fecal mass in left iliac fossa were analyzed between two group and all were significantly higher in children with functional constipation group.Children of school,where toilet numbers were inadequate had 2.5 times more constipation risk in comparison to children of school with adequate toilet number(OR=2.493,95%CI:1.214-5.120).Children who feel embarrassed to use toilet at school,had 3.6 times higher risk of constipation(OR=3.552,95%CI:1.435-8.794).Here children with H/O affected sibs and parents/grandparents had 4 and 2.6 times more chance of constipation respectively in comparison to children without H/O affected sibs(OR=3.977,95%CI:1.884–8.397)and parents/grandparents(OR=2.569,95%CI:1.172-5.629).Children with inadequate fluid intake had 2 times more risk of constipation in comparison to children with adequate fluid intake(OR=1.972,95%CI:1.135-3.426).Children who passed electronic screen time of>2 h/d had 2 times more chance of constipation in comparison to children who passed electronic screen time<2 h(OR=2.138,95%CI:1.063-4.301).CONCLUSION Constipation is not uncommon in Bangladeshi school aged children.Inadequate toilet number,family history of constipation,inadequate fluid intake,feeling embarrassed to use toilet at school,and electronic screen time for>2 h/d were found as risk factors in the present study for functional constipation.

1例血管淋巴组织增生伴嗜酸性细胞增多患者发生严重主动脉粥样硬化并发展为外周T细胞淋巴瘤

We report an adolescent girl with a history of angiolymphoid hyperplasia with eosinophilia (ALHE) diagnosed at the age of 10 years. The patient also suffered from chronic persistent multiresistant herpes simplex virus infection. Atherosclerotic occlusive disease of the abdominal aorta and its major branches was observed at the age of 17 years, necessitating vascular surgical intervention 1 year later because of disease progression. Histological examination of the aorta disclosed widespread atherosclerosis and high levels of gene expression of both T-helper cell type (Th) 1-and Th2-derived cytokines. This suggests that a highly stimulated systemic immune response including increased production of both Th1-and Th2-derived cytokines such as interferon-γand interleukin-4 may result in severe atherosclerotic lesions at a very young age. In addition, the patient developed a peripheral T-cell lymphoma at the age of 18 years. Neither systemic atherosclerosis nor T-cell lymphoma has been reported in association with ALHE. It is suggested that a highly stimulated dysfunctional immune response may play a key role in persistent inflammatory disease and premature development of atherosclerosis as well as malignant transformation of T cells.

Applying the WHO instead of CDC growth charts may double obesity rates

Aims: This study compares the WHO (2007) and the National Health Examination Survey (NHANES III) reference intervals and investigates the differences when applied on a Canadian cohort of older children and adolescents. Methods: We calculated height, weight and BMI z-scores of 4375 consecutive patients (1993 female, 45.6%) aged 5 - 20 years attending outpatient clinics at a single tertiary care centre using reference data of the latest NHANES (III) survey and the WHO (2007) growth charts. To address age dependency, data was stratified into age groups. Results: Using the NHANES III reference intervals, medians of weight (+0.46), height (+0.29) and BMI z-scores (+0.46) were significantly non-zero. The WHO (2007) growth charts yielded medians of +2.05, +0.32, +0.53 for weight, height and BMI z-scores respectively, all significantly non-zero. When comparing both growth charts, Canadian children had significantly different weight and BMI z-scores (p 95th percentile) doubled from 8.6% to 16.0%. A significant age dependency was observed with higher WHO (2007) weight z-scores (>7 years) and higher BMI z-scores (7 to 13 years) and no significant difference was observed for height z-scores across all age groups. Gender differences were observed for weight z-scores (>9 years) and BMI (males: 9 - 11 years, p = 0.0118;11 - 13 years, p = 0.0069) whereas no significant difference was found in height z-scores across all age groups. Conclusion: Our results reveal substantial differences between both reference populations and thus interpretation needs be done with caution, especially when labelling results as abnormal.

Antibiotics Prophylaxis in Patients with CAKUT, Does It Actually Prevent UTI? A Single Center Experience at South Africa

Background: Congenital anomalies of the kidney and urinary tract (CAKUT) are a well-documented risk factor for the development of urinary tract infection (UTI) in children. Prevention of UTI in this group of patients is advocated due to their increased risk of renal scarring, hypertension and end stage kidney failure. Methods: A 10-year retrospective review of CAKUT patients at the Johannesburg Academic Hospital, who were placed on prophylactic antibiotics over a certain period was done. The rate of UTI, the types of causative organisms isolated and the efficacy of prophylactic antibiotics in preventing UTI were documented. Results: Thirty-six (36) out of 134 patients had been started on prophylactic antibiotics after the diagnosis of CAKUT was made. There was a statistically significant association between the use of prophylactic antibiotics and the rate of UTI (p Conclusion: Antibiotic prophylaxis was very effective in decreasing the rate of UTI in our cohort of patients with CAKUT.

Evaluation of Glomerular Hyperfiltration and Albuminuria in Sickle Cell Disease Adolescents: Cross-Sectional Retrospective Study

Background: Sickle Cell Disease (SCD) renal abnormalities commence early in childhood. The glomerular abnormalities, glomerular hyperfiltration and albuminuria are the most prevalent. However, these SCD glomerulopathies have not been considered exclusively in the adolescent age group. Objective: To determine the prevalence of glomerular hyperfiltration and albuminuria as well as identify the determinants for glomerular hyperfiltration in adolescents with SCD. Patients and Methods: The electronic patient records of 153 adolescents with SCD aged 10 - <19 years, attending the Paediatrics Haematology Clinic at Evelina London Children’s Hospital, United Kingdom, were reviewed from the 10th to 23rd June 2019. Clinical information and laboratory parameters were obtained. The glomerular filtration rate was derived using the Bedside Schwartz’s method. Grouping of the adolescents was based on the presence and absence of glomerular hyperfiltration, which was defined as glomerular filtration rate > 140 ml/min/m2. The presence of albuminuria was defined as urine albumin-to-creatinine ratio > 3 mg/mmol or protein-to-creatinine ratio of >15 mg/mmol. The clinical and laboratory determinants of glomerular hyperfiltration in the total study population were investigated. Result: Prevalence of glomerular hyperfiltration was 33.3% in the adolescents studied, and that of albuminuria was 15.7% amongst the SCD adolescents studied, of which 13.7% of those with glomerular hyperfiltration also had albuminuria. On univariable analysis, the SCD adolescents with glomerular hyperfiltration had significantly lower weight (48.0 ± 18.0 versus 54.8 ± 17.0 kg;p = 0.02), height (155.1 ± 13.1 versus 160.6 ± 13.1 cm;p = 0.01), body mass index (19.4 ± 5.0 versus 21.0 ± 4.3;p = 0.04), haemoglobin level (88.7 ± 13.3 versus 98.1 ± 21.7 g/L;p = 0.001), and serum creatinine level (0.4 ± 0.1 versus 0.6 ± 0.2 mg/dl;p = 0.0001) as compared to those with no glomerular hyperfiltration. The SCD adolescents with glomerular hyperfiltration also had significantly higher lactate dehydrogenase levels (525.9 ± 180.3 versus 449.6 ± 170.3 IU/L;p = 0.01) than those with no glomerular hyperfiltration. But, multivariable analysis revealed no associations. Conclusion: This study revealed that the prevalence of glomerular hyperfiltration in SCD children in the adolescent age group is high, and the high glomerular filtration rates begin to decline toward normal values in middle adolescence.

Journey of a patient with scleroderma from renal failure up to kidney transplantation

The increased awareness of systemic sclerosis(SS)and its pathogenetic background made the management of this disease more amenable than previously thought.However,scleroderma renal crisis(SRC)is a rarely seen as an associated disorder that may involve 2%-15%of SS patients.Patients presented with earlier,rapidly progressing,diffuse cutaneous SS disease,mostly in the first 3-5 years after non-Raynaud clinical manifestations,are more vulnerable to develop SRC.SRC comprises a collection of acute,mostly symptomatic rise in blood pressure,elevation in serum creatinine concentrations,oliguria and thrombotic microangiopathy in almost 50%of cases.The advent of the antihypertensive angiotensin converting enzyme inhibitors in 1980 was associated with significant improvement in SRC prognosis.In a scleroderma patient maintained on regular dialysis;every effort should be exerted to declare any possible evidence of renal recovery.A given period of almost two years has been suggested prior to proceeding in a kidney transplant(KTx).Of note,SS patients on dialysis have the highest opportunity of renal recovery and withdrawal from dialysis as compared to other causes of end-stage renal disease(ESRD).KTx that is the best well-known therapeutic option for ESRD patients can also be offered to SS patients.Compared to other primary renal diseases,SS-related ESRD was considered for a long period of poor patient and allograft survivals.Pulmonary involvement in an SS patient is considered a strong post-transplant independent risk factor of death.Recurrence of SRC after transplantation has been observed in some patients.However,an excellent post-transplant patient and graft outcome have been recently reported.Consequently,the absence of extrarenal manifestations in an SS-induced ESRD patient can be accepted as a robust indicator for a successful KTx.

90 min内和3 min内静脉滴注蔗糖铁疗法所引起的促红细胞生成素依赖患儿不良事件的发生率均不高

Aim: To define the adverse events following two different rates and methods of intravenous iron sucrose infusions in children with anaemia due to chronic renal impairment. Methods: Two prospective observational studies were undertaken to characterize the adverse events following iron sucrose administration in children with renal impairment and on erythropoietin. Between January 1999 and April 2003, 5 mgkg of intravenous (IV) iron sucrose was given over 90 min and repeated 24 h later. Between May 2003 and September 2004, in children with better venous access, a single dose of 2 mgkg of IV iron sucrose was administered over 3 min during an outpatient clinic visit and haemodialysis sessions. Following infusions, children were monitored for immediate and delayed adverse events. All such events were documented and dealt with appropriately. Test doses were not used. Results: A total of 870 infusions over 90 min were administered to 72 children. Three children developed abdominal pain. One child developed worsening of hypertension (not related to iron sucrose). Sixty-five doses were administered over 3 min to 20 children, and six minor adverse events were documented. Conclusion: Although 90 min infusion is associated with fewer adverse events, no lifethreatening events were documented in either method.

小儿系统性红斑狼疮时的急性胰腺炎

Acute pancreatitis(AP)rarely complicates the clinical course of systemic lupus erythematosus(SLE).AP as the initial manifestation of SLE is exceptional,but its outcome is often fatal.Corticosteroids have been suspected to play a role in the development of AP,but the therapeutic benefit seems to be far above the risk of exacerbation of pancreatic lesions.We report a 13-y-old girl presenting with arthralgia and malaise,followed by abdominal pain,generalized oedema and haemodynamic instability.Increased CRP(325 ng/ml),serum amylase(14 000 IU/l)and lipase(2500 IU/l)levels suggested AP.Acute anuric renal failure required haemodialysis.Multiorgan involvement suggested SLE,which was confirmed 3 d later by increased anti-ds-DNA levels.Three methylprednisolone pulses were administered promptly,followed by oral prednisone(1.5 mg/kg/d)and six pulses of cyclophosphamide(500 mg/1.73m 2/2 wk).Mycophenolatemofetil was introduced for long-term disease control.Amylase and lipase levels decreased over 4wk.Renal function was normal after 3wk and proteinuria negative after 6 wk.Conclusion:This case suggests that steroid pulse therapy should be promptly administered if clinical and biochemical investigations suggest SLE to be responsible for AP.Aggressive treatment may be life saving.

Tubulointerstitial nephritis and uveitis syndrome post-COVID-19

To the editor:The angiotensin-converting-enzyme-2(ACE2)receptor is expressed in many extrapulmonary organs:eyes(conjunctival,corneal,and limbal epithelial cell,retina),nerves,vessels,small intestine enterocytes,kidney proximal tubules.

儿童常染色体显性遗传性多囊肾病--现在筛查有益于以后的救治吗？

儿童常染色体显性遗传性多囊。肾病（Autosomal dominant polycystic kidney disease，ADPKD）也就是以前众所周知的“成人多囊肾”，大多数的病例直到成年期才被发现。然而，多囊肾病比较常见的并发症比如高血压、心血管疾病等可能在疾病被发现前就已经发生了。