A Retrospective Analysis of Systemic Bartonella henselae Infection in Children

Systemic Bartonella henselae infection, also known as cat-scratch disease (CSD), presents a diagnostic challenge due to the variability of clinical manifestations and the potential for serological cross-reactivity with other organisms. This study aimed to retrospectively analyze the epidemiological, clinical, laboratory, and imaging characteristics of pediatric patients diagnosed with systemic B. henselae infection, to improve understanding and facilitate timely diagnosis and treatment. We conducted a 10-year retrospective study at the "Louis Turcanu" Children's Emergency Hospital and private clinics in Timisoara, Romania, reviewing records for confirmed cases of B. henselae infection from January 2014 to January 2024. The study adhered to the Declaration of Helsinki and received approval from the Institutional Review Board. Diagnostic criteria included contact with animals, prolonged fever, hematological and/or hepatosplenic manifestations, and positive serological tests for B. henselae. Nineteen pediatric patients were identified with a median age of 8.1 years. The majority were exposed to felines (94.7%), reflecting the disease's epidemiological profile. Clinical findings highlighted fever (47.4%), lymphadenopathy (78.9%), and less frequently, abdominal pain and headache (both 10.5%). Laboratory analyses revealed a mean hemoglobin of 12.6 mg/dL, WBC count of 13.1 × 103 cells/microliter, and platelet count of 340.6 × 103 per microliter. Significant findings included elevation in ESR and CRP in 47.4% and 21.1% of patients, respectively, and high seropositivity rates for B. henselae IgM (63.2%) and IgG (94.7%). Imaging studies demonstrated widespread lymphadenopathy and occasional splenomegaly and hepatic microabscesses. All patients received antibiotic therapy, with azithromycin being the most commonly used (94.7%). Co-infections with Epstein-Barr Virus, Cytomegalovirus, and Toxoplasma gondii were documented, indicating the complex infectious status of the patients. Systemic B. henselae infection in children predominantly manifests with fever and lymphadenopathy, with a significant history of exposure to felines. Laboratory and imaging findings support the diagnosis, which is further complicated by potential co-infections. Effective antibiotic therapy, primarily with azithromycin, underscores the need for comprehensive diagnostic and treatment strategies. This study emphasizes the importance of considering systemic B. henselae infection in pediatric patients with prolonged fever and contact with cats, to ensure timely and appropriate treatment.

Case Report: Vascular access in paediatric haemodialysis patients-creating and maintaining the patency of an arteriovenous fistula

Introduction

Paediatric vascular access is a demanding field. The need for a multidisciplinary team is mandatory in children with end-stage kidney disease (ESKD). Central venous catheters (CVCs) remain the preferred option worldwide. Recent emerging data demonstrated the benefits of using arteriovenous fistulas (AVFs) in the paediatric population for long-term vascular access. The small vessel size in children represents a surgical challenge for vascular access.

Case presentation

We report three cases from our haemodialysis department and the difficulty in maintaining permanent vascular access. The first case is an adolescent girl who required a change in vascular approach after multiple central venous catheter (CVC) infections and catheter thrombosis secondary to thrombophilia. Three AVFs were performed but failure occurred early. The patient was also diagnosed with a complex vascular thrombosis with total occlusion of the inferior vena cava and completed distal thrombosis of the superior vena cava. A permanent CVC was placed in the right jugular vein with the tip in the azygos vein. The second case is of an adolescent boy with systemic vasculitis with multiple CVC infections secondary to immunosuppression. The first thrombosis of two right AVFs occurred early with the development of a pseudo-aneurysm that required surgical intervention. The left brachial-cephalic fistula required surgery for closing the collaterals, repositioning and superficialisation. The third case is an adolescent boy with one surgical stage brachial-basilic left AVF and difficulties in venous puncturing.

Conclusion

Vascular access in paediatric haemodialysis remains a demanding field. There is a need for a multidisciplinary team, consisting of a vascular surgeon and an interventional radiologist specialising in children.

Phenotype of Idiopathic Infantile Hypercalcemia Associated with the Heterozygous Pathogenic Variant of SLC34A1 and CYP24A1

Idiopathic infantile hypercalcemia (IIH) is a rare genetic disease, also called hypersensitivity to vitamin D3. The molecular heterogeneity allows for the differentiation between the two forms; IIH type 1 caused by CYP24A1 genetic variants and IIH type 2 associated with SLC34A1 mutations. The affected individuals express a variety of symptoms: hypercalcemia, hypercalciuria, suppressed intact parathormone levels (PTH), nephrocalcinosis, elevated levels of serum 1,25 (OH)2-vitamin D3 or inappropriately normal levels, and kidney phosphate wasting. The present paper describes three cases of IIH with heterozygous mutations in SLC34A1 and CYP24A1 genes, respectively. The genetic diagnosis is of paramount importance for proper treatment and the prediction of long-term outcomes.

Trends in mortality and comorbidities in hemodialysis patients between 2012 and 2017 in an East-European Country: a retrospective study

PURPOSE

The aim of this study was to evidence trends and changes in mortality, comorbid conditions, prognosis, and causes of death after 5 years of continuous evolution of hemodialysis (HD) patients in Romania.

METHODS

We included two cohorts of stable HD patients (901 from 2012 and 1396 from 2017). Both cohorts were followed up for 1 year. The 5-year survivors of the 2012 cohort were identified in 2017 and their data changes were assessed.

RESULTS

The 2017 patients were older, with longer time on dialysis, higher serum creatinine and urea levels, and required higher ultrafiltration volume per dialysis. They also had lower hemoglobin, lower C-reactive protein, higher albumin, higher calcium bicarbonate, and higher parathyroidectomy prevalence. The 2017 cohort presented with lower average dialysis flow, less administration of iron sucrose, had more catheters, lower hepatitis C prevalence, higher diabetes mellitus prevalence, higher heart valve calcifications, higher heart rate disorders, higher prevalence of left ventricular hypertrophy, and lower ejection fraction. Cardiovascular disease was the main cause of death in both years (50% in 2012 and 45.6% in 2017), followed by sepsis and cancer. The mortality was higher in 2017 compared to 2012 (14.1 vs 6.6%). The 5-year mortality was 37.2% with an average of 7.44%/year. The risk of death increased with age, higher C-reactive protein, higher phosphate, lower hemoglobin, and lower albumin.

CONCLUSION

Cardiovascular disease remains the main causes of death in HD-treated patients but with decreasing trend. Developing regional therapeutic strategies for quality care with early intervention will most likely improve mortality.

Kinetic Estimated Glomerular Filtration Rate in Predicting Paediatric Acute Kidney Disease

Kinetic estimation of glomerular filtration rate (KeGFR) has proved its utility in predicting acute kidney injury (AKI) in both adults and children. Our objective is to assess the clinical utility of KeGFR in predicting AKI severity and progression to acute kidney disease (AKD) in patients already diagnosed with AKI and to examine major adverse kidney events at 30 days (MAKE30). We retrospectively calculated the KeGFR within the first 24 h of identified AKI (KeGFR1) and in the 24 h prior to AKD (KeGFR2) in all admitted children under 18 years old. The cohort consisted of 803 patients with AKI. We proposed a new classification of KeGFR stages, from 1 to 5, and assessed the predictive value of KeGFR stages for AKD development and MAKE30. AKI severity was associated with lower KeGFRs. KeGFR1 and KeGFR2 predicted AKD with AUC values between 0.777 and 0.841 respectively, p < 0.001. KeGFR2 had the best performance in predicting MAKE30 (AUC of 0.819) with a sensitivity of 66.67% and specificity 87.7%. KeGFR1 stage 3, 4 and 5 increased the risk of AKD by 3.07, 6.56 and 28.07 times, respectively, while KeGFR2 stage 2, 3, 4 and 5 increased the risk of AKD 2.79, 3.58, 32.75 and 80.14 times. Stage 5 KeGFR1 and KeGFR2 stages 3, 4 and 5 increased the risk of MAKE30 by 7.77, 4.23. 5.89 and 69.42 times in the adjusted models. KeGFR proved to be a useful tool in AKI settings. KeGFR dynamics can predict AKI severity, duration and outcomes.

Acute kidney injury in children: incidence, awareness and outcome-a retrospective cohort study

The primary objective was to determine the epidemiologic influence of AKI awareness among physicians in a mixt paediatric population, including neonates. This single-centre, multiyear, observational retrospective study included all admitted patients between first of July 2014 and 31 December 2021. AKI was identified in 2194 patients out of the 128,036 hospital admissions with 129,936 serum creatinine measurements. Matching comparisons were used between AKI aware and AKI non-aware patients. The overall incidence of AKI was 1.65%. Stage 1 was identified in 24.24% of the AKI cases, stage 2 in 31.03% and stage 3 in 44.71%. The most prevalent cause of AKI was represented by prerenal AKI in 85.64% of the cases, followed by 12.16% renal causes respectively 2.18% postrenal causes. Exposure to sepsis, critical illness, hypovolemic shock and mechanical ventilation increased mortality by 2.09, 4.69, 4.64- and 4.93-times (p = 0.001). Cancer and heart failure increased mortality by 4.22 (p < 0.001) respectively 2.17 times (p = 0.001). The presence of AKI increased mortality by 79.11 times while only half of the AKI associated deaths were recognized by physicians. AKI increased hospitalization more than 4 times the average stay. AKI awareness was dependent of lower age and severity. Also, awareness increased mortality and prolonged hospitalization. 1 in 3 neonates and 1 in 4 children were AKI aware. The physician's awareness of AKI diagnosis is in general low due to lack of appliance of current guidelines in exploring exposures and susceptibilities for AKI screening.

Chronic kidney disease in cancer patients, the analysis of a large oncology database from Eastern Europe

Introduction

Kidney dysfunction is prevalent in oncology patients and has an impact on their treatment and quality of life. The aim of our study was to analyze the prevalence of CKD in a large cohort of several types of cancer patients in an East European Region.

Material and methods

We conducted an observational retrospective cohort study on 5831 consecutive, biopsy-diagnosed cancer patients between January 2019 –December 2020 in the largest oncology hospital and outpatient clinic in Western Romania. 4342 subjects were included in the statistical analysis.

Results and discussion

From the 24 cancer types, the most prevalent cancers were represented by: breast (22.02%), lung (10.18%) and colonic cancer (9.51%). The prevalence of CKD (G3 –G5) was 12.27% after the first year of follow-up and 13.42 after the second year. The prevalence of CKD was higher in patients with renal (50%), urinary tract (33.6%) and pancreatic cancers (19.6%) and lower in patients with colonic cancers (5.3%) and brain tumors (2.5%). At the end of our 2-year survey period, 0,7% of the CKD cases had an eGFR around 6 ml/min/1.73m2 –an indication for renal replacement therapy.

Conclusion

Oncology patients have a significantly higher prevalence of CKD compared to the general population, dependent of the age of the patients and the type of cancer. The prevalence of advanced CKD was surprisingly high (stages G4-G5 Pre-Dialysis 22.15%) one third of the CKD- G5 patients having indication for initiation of renal replacement therapy. An onco- nephrology team should be needed for the best medical care of these patients.

MO1024: Exposures and Susceptibilities in Paediatric Acute Kidney Injury—Impact on Awareness and Survival

BACKGROUND AND AIMS

Acute kidney injury (AKI) is a growing global healthcare problem in the adult and paediatric population. In comparison with the adult population where the coexisting chronic conditions (e.g. diabetes, hypertension) increase the mortality risk during AKI, in children without chronic conditions one can assess the direct impact of AKI on mortality. Current paediatric studies state the need for increased awareness of AKI, for identifying susceptibilities and for the need to correct modifiable exposures in order to improve outcomes.

METHOD

We conducted a retrospective observational study in the ‘Louis Turcanu’ Emergency County Hospital for Children in Timisoara, Romania. Data were extracted from the hospital electronic database, between 1 January 2014 and 31 December 2020. The study cohort included 127 457 patients (aged 1 day–18 years) who had at least two serum creatinine levels determined during the same hospital admission. AKI was defined and staged according to Kidney Disease Improving Global Outcome (KDIGO) guidelines (and 2021 Consensus Conference) using Acute Kidney Injury Network (AKIN) criteria. Baseline serum creatinine was considered the nadir serum creatinine in 7 days from admission. AKI awareness in different medical clinics was considered the recognition of AKI diagnosis during admission as noted in the medical records according to ICD-10 Clinical Modification codes (N17.0, N17.1, N17.2, N17.8, N19, N99.0 and P96.0). AKI non-awareness was considered in patients presenting AKI according to AKIN without diagnoses recognition in the medical reports.

RESULTS

Over the 7-year study, 1867 patients developed AKI (out of 127 457 hospital admissions). The overall AKI incidence was 1.46%. The diagnosis of AKI was lacking (non-awareness) in 72.5% of AKI cases. We evaluated the exposures and susceptibilities of AKI patients and their impact on awareness and mortality. Taking into account the fact that the study addressed paediatric patients, exposures and susceptibilities have been changed accordingly. The considered exposures were: sepsis, critical illness, circulatory shock, burns, trauma, major non-cardiac surgery, nephrotoxic drugs, contact with poisonous plants and mechanical ventilation. Our regression equation proved to be a good fit for the model, explaining only 3.8% of AKI awareness (R2 = 0.038) and 22.9% of death events (R2 = 0.229). AKI awareness increases with the presence of dehydration (by 2.29-fold, P &lt; .05) and heart failure (by 2.54-fold, P &lt; .001). The risk of death increases with the presence of prematurity (by 2.33-fold, P &lt; .0001), cancer (by 2.45-fold, P &lt; .0001), anaemia (by 4.06-fold, P &lt; .0001) and chronic illness (by 2.65-fold, P &lt; .0001). The susceptibilities were: female gender, chronic kidney disease, chronic diseases (heart, lung, liver), diabetes mellitus, cancer, anaemia, very low birth weight, heart failure, arterial hypertension and stem cell transplant. Our regression equation proved to be a good fit for the model, explaining only 9.4% of AKI awareness (R2 = 0.094) and 43.6% of deaths (R2 = 0.436). The awareness increases with the presence of sepsis (by 1.73-fold, P &lt; .0001), of critical illness (by 2.41-fold, P &lt; .0001) and mechanical ventilation (by 1.54-fold, P &lt; .0001). The risk of death increases in the presence of sepsis (by 3.26-fold, P &lt; .0001), of critical illness (by 7.42-fold, P &lt; .0001), of mechanical ventilation (by 10.58-fold, P &lt; .0001) and hypovolemic shock (by 10.58-fold, P &lt; .0001).

CONCLUSION

The presence of more severe exposures and susceptibilities increased the awareness of AKI but also increased the risk of death. The diagnosis of AKI in our medical records is late, therefore late diagnosis has no benefits concerning the evolution and mortality of paediatric patients with AKI.

MO1030: Aki Awareness and Survival in Paediatric Patients in a Western Romania Emergency Hospitala 7 Years Retrospective Cohort Study

BACKGROUND AND AIMS

Acute kidney injury (AKI) is a globally increasing healthcare problem being usually associated with low awareness and high mortality. Several large studies have drawn attention to the increasing cases of AKI in the paediatric population, mostly in the neonatal setting but also in critically ill patients and young adults. It was suggested that increased awareness could lead to early diagnosis and intervention, therefore improved survival.

METHOD

We performed a retrospective cohort study in ‘Louis Turcanu’ Emergency County Hospital for Children in Timisoara, Romania. Data have been extracted from the hospital electronic database, between 1 January 2014 and 31 December 2020. The cohort included 127 457 patients (aged 1 day–18 years) who had at least two serum creatinine levels determined during the same hospital admission. AKI was defined and staged according to Kidney Disease Improving Global Outcomes (KDIGO) guidelines (and 2021 Consensus conference). AKI awareness was considered the recognition of AKI diagnosis during admission as noted in the medical records according to ICD-10 Clinical Modification codes (N17.0, N17.1, N17.2, N17.8, N19, N99.0 and P96.0). AKI non-awareness was considered in patients presenting AKI criteria without diagnoses recognition in the medical records. We considered baseline serum creatinine the lowest serum creatinine value in 7 days from admission.

RESULTS

Over the 7-year period, 1867 patients developed AKI out of 127 457 hospital admissions. The overall AKI incidence was 1.46% and the annual incidence increased 3.95-fold during the 7 years (from 0.6% in the first year to 2.37% in the seventh). Staging AKI according to Acute Kidney Injury Network (AKIN), stage 1 was identified by us in 23.2% of the AKI cases, stage 2 in 31.3% and stage 3 in 45.5%. AKI awareness (as defined above) was 27.5% (overall), being significantly increased in premature babies (P &lt; .012), full-term neonates (P &lt; .0001) and toddlers (P &lt; .0001). In AKI stages 1 and 2 the diagnosis of AKI (included in the patient's documents according to ICD 10) was less frequent as compared to stage 3. So, we considered that AKI awareness is significantly lower in early AKI stages (1 and 2) (i.e.16.9 and 19.7% respectively) as compared with late AKI (stage 3) 38.3% (P &lt; .001). Only 19 patients (1.01%) required renal replacement therapy (RRT). During the 7-year period, the all-cause mortality in our cohort was 0.32% (410 patients died) being 0.13% in the no AKI patients and 12.8% in the AKI group (57.89% in patients treated with RRT). Odds ratio (OR) of death in the AKI diagnosed patients (aware and non-aware) was 107.67 versus non-AKI patients (P &lt; .0001). The risk of death in the AKI aware group was 3.3 higher versus AKI non-aware group (P &lt; .001). These not expected, reverse results, are attributable to a very low awareness (as defined by us in Methods) in the early stages of AKI. A higher mortality rate was associated with AKIN stage 3—OR of 1.53 (P &lt; .001). The average length of hospital stay was significantly higher in AKI patients (20.79 days) as compared with the no AKI group (5.74 days).

CONCLUSION

The awareness of AKI in children remains a problem worldwide with implications on the survival of patients. Being aware of AKI means early identifying the risk of AKI, early diagnosis and early intervention. As it was presented above late diagnosis and awareness are associated with high mortality rate and the need for interventions (RRT) associated with high mortality risk.

MO525CHRONIC KIDNEY DISEASE IN NEOPLASIA PATIENTS, THE ANALYSIS OF A LARGE CANCER DATABASE

Background and Aims

Neoplasia is considered a risk factor for the development of CKD, for many reasons: aggressive and repeated therapeutic interventions, malnutrition, hyperuricemia and the disease per se. Taking into account the improved cancer survival due to novel therapeutic interventions, the possibility of cancer patients with CKD to reach advanced CKD stages is increasing. The information about cancer patients and CKD is still scarce. This paper tends to fill the gap by analyzing the relation between cancer patients and CKD in a large cancer database from western Romania.

Method

5831 patients (3365 female, average age 62.6 +/- 10.4 years, median age 64 years) with neoplasia from a large cancer database in Western Romania have been randomly assigned to this study. Serum creatinine at inclusion was used to estimate baseline GFR by the CKD-Epi formula. During the 2-year follow-up, serum creatinine was repeatedly determined in order to estimate GFR (at least 2 determinations). CKD was defined as eGFR &lt; 60ml/min/1.73m2 persistent for more than 3 months. For our assessment, we used the available personal and medical data from the analyzed database. For comparison, we used the CKD epidemiology data in the general population of Romania.

Results

GFR &lt; 60ml/min/1.73m2 was identified at inclusion in 11.88% of the cases. The prevalence of CKD according to GFR criteria was 14.49% after the first year of follow-up, significantly higher if compared to the general population (8.8% - 2008) (p&lt;0.0001). In the second year, the prevalence increased to 14.98% (with 3%) and the average decrease of eGFR was 4.7ml/min/year.

In the examined database, patients with breast cancers (1317 cases), lung (551), uterus (427), prostate (431) and colonic cancers (498) were dominant. The prevalence of CKD was dependent of the type of cancer, being significantly higher in patients with renal cancer (48,71%), urinary bladder cancers (34,1%), multiple myeloma (20%), liver carcinoma (20%) and pancreatic cancers (19.6%). The prevalence of CKD was significantly lower in patients with rectum cancers (9.9%), testicle cancers 8.8% and in patients with brain tumors (7.1%).

The influence of CKD on the survival of cancer patients could not be estimated due to the short follow-up time.

Conclusion

The prevalence of CKD in patients with neoplasia is higher than in the general population and increasing in time, but according to our results, the rate of decrease of the kidney function is not high. The prevalence of CKD is dependent of the type of cancer being higher in renal, urinary bladder, liver, pancreatic cancers and multiple myeloma and lower in testicle cancers and in brain tumors. Taking in account the increasing survival of cancer patients, the probability to reach ESKD is increasing also and that could influence the profile and needs of patients admitted to renal replacement therapy.