Evaluation of carotid intima media thickness in children with idiopathic nephrotic syndrome

AIM

Aim of the study was to determine if carotid intima media thickness in children with idiopathic nephrotic syndrome is greater than in healthy subjects, and to assess whether carotid intima media thickness in children with nephrotic syndrome is associated with clinical (including disease duration, cumulative dose of steroids, number of relapses) and biochemical parameters.

METHODS

A cross-sectional study included 40 patients with nephrotic syndrome (mean age 11.7±4.7 years). Steroid dependent nephrotic syndrome was established in 32 patients (80%), while 8 (20%) had steroid resistant nephrotic syndrome. Control group consisted of 20 age and gender matched healthy children. Blood pressure based on 24-h ambulatory blood pressure monitoring (ABPM), carotid intima media thickness, fasting glucose, insulin, HbA1c, lipid concentrations were measured in all children.

RESULTS

A significant difference was detected in carotid intima media thickness values (P=0.036). Children with nephrotic syndrome had significantly greater carotid intima media thickness compared with healthy children (0.42±0.06 and 0.38±0.03mm). Carotid intima-media thickness was positively associated with duration of nephrotic syndrome (r=0.45; P=0.004), body mass index (r=0.48; P=0.002), daytime systolic blood pressure (r=0.46; P=0.003) and night-time systolic blood pressure (r=0.52; P=0.001). Multiple linear regression showed that duration of nephrotic syndrome was the only independent predictor of carotid intima media thickness in children with nephrotic syndrome (R²=0.244; β=0.327; P=0.037).

CONCLUSION

The findings of the present study suggest subclinical vascular damage in patients with nephrotic syndrome. Duration of nephrotic syndrome was the only independent predictor of carotid intima media thickness.

Whole-Exome Sequencing Identifies Causative Mutations in Families with Congenital Anomalies of the Kidney and Urinary Tract

BACKGROUND

Congenital anomalies of the kidney and urinary tract (CAKUT) are the most prevalent cause of kidney disease in the first three decades of life. Previous gene panel studies showed monogenic causation in up to 12% of patients with CAKUT.

METHODS

We applied whole-exome sequencing to analyze the genotypes of individuals from 232 families with CAKUT, evaluating for mutations in single genes known to cause human CAKUT and genes known to cause CAKUT in mice. In consanguineous or multiplex families, we additionally performed a search for novel monogenic causes of CAKUT.

RESULTS

In 29 families (13%), we detected a causative mutation in a known gene for isolated or syndromic CAKUT that sufficiently explained the patient's CAKUT phenotype. In three families (1%), we detected a mutation in a gene reported to cause a phenocopy of CAKUT. In 15 of 155 families with isolated CAKUT, we detected deleterious mutations in syndromic CAKUT genes. Our additional search for novel monogenic causes of CAKUT in consanguineous and multiplex families revealed a potential single, novel monogenic CAKUT gene in 19 of 232 families (8%).

CONCLUSIONS

We identified monogenic mutations in a known human CAKUT gene or CAKUT phenocopy gene as the cause of disease in 14% of the CAKUT families in this study. Whole-exome sequencing provides an etiologic diagnosis in a high fraction of patients with CAKUT and will provide a new basis for the mechanistic understanding of CAKUT.

The Child Health Care System of Serbia

The health care system in Serbia is based on a network of public health institutions funded by the National Health Insurance and from the state budget. Access to public health institutions is free. Preventive and curative services are provided at the local level in primary health care centers. Over the past 5-7 years, the number of pediatricians in primary health care centers decreased because of reduced number of applicants for pediatric training, which endangers the maintenance of the traditional model of pediatric care. Secondary medical care is offered in pediatric departments of local and regional general hospitals or outpatient clinics, and in specialized hospitals for children or adults. Tertiary medical care is provided by inpatient or outpatient subspecialty services in 5 major university children's clinics. The health reforms undertaken in the recent 10 years have aimed at strengthening preventive health care and reducing the overall costs for pediatric care. Current initiatives of the Ministry of Health and national pediatric associations are aimed at reestablishing and strengthening the capacity of the primary pediatric health care model by increasing the number of physicians and developing new processes of care.

Associated extrarenal vascular diseases may complicate the treatment and outcome of renovascular hypertension

AIM

This studied reviewed renovascular hypertension (RVH) due to renal artery stenosis (RAS) in two Serbian paediatric centres from 2001 to 2013.

METHODS

The patients' demographic data, underlying syndromes, blood pressure (BP), antihypertensive treatments and outcomes were reviewed.

RESULTS

The incidence of RVH was 1.9 per million children per year during the study period, and there were 25 patients with RAS, aged 10.4 ± 5.2 years. At presentation, their mean blood pressure (BP) standard deviation scores were 6.9 ± 3.4 systolic and 5.2 ± 2.6 diastolic. BP loads on 24-hour ambulatory BP were 88 ± 14% systolic and 80 ± 29% diastolic. We found that 72% had fibromuscular dysplasia and 28% had underlying syndromes. RAS was unilateral in 64% and bilateral in 28%, and 8% had RAS of a single kidney. Antihypertensive treatment included antihypertensive drugs (100%), percutaneous transluminal angioplasty (92%), renal auto-transplantation (16%), surgical revascularisation (12%) and nephrectomy (12%). After 4.4 ± 3.6 years of follow-up, high BP was cured in 40% of the patients and 39.4% of the kidneys and improved in 48% (75.7%), with BP decreases of 20.3 ± 3.7% systolic and 16.3 ± 6.2% diastolic.

CONCLUSION

Fibromuscular dysplasia was the most common cause of RVH in this study, and hypertension was cured or improved in 88% of the patients.

Glomerular nestin expression: possible predictor of outcome of focal segmental glomerulosclerosis in children

BACKGROUND

A high prevalence of chronic kidney disease among children with focal segmental glomerulosclerosis (FSGS) leads to a permanent quest for good predictors of kidney dysfunction. Thus, we carried out a retrospective cohort study in order to examine known clinical and morphological predictors of adverse outcome, as well as to investigate glomerular nestin expression as a potential new early predictor of kidney dysfunction in children with FSGS. Relationships between nestin expression and clinical and morphological findings were also investigated.

METHODS

Among 649 renal biopsy samples, obtained from two children's hospitals, FSGS was diagnosed in 60 children. Thirty-eight patients, who met the criteria for this study, were followed up for 9.0 ± 5.2 years. Using Kaplan-Meier and Cox's regression analysis, potential clinical and morphological predictors were applied in two models of prediction: after disease onset and after the biopsy.

RESULTS

The present study revealed the following significant predictors of kidney dysfunction: patients' ages at disease onset, as well as age at biopsy, resistance to corticosteroid treatment, serum creatinine level, urine protein/creatinine ratio, vascular involvement, tubular atrophy, interstitial fibrosis, and decreased glomerular nestin expression.

CONCLUSIONS

The most important finding of our study is that nestin can be used as a potential new early morphological predictor of kidney dysfunction in childhood onset of FSGS, since nestin has been obviously decreased in both sclerotic and normal glomeruli seen by light microscopy.

Growth in children with chronic kidney disease: 13 years follow up study

BACKGROUND

Growth retardation is one of the most visible comorbid conditions of chronic kidney disease (CKD) in children. To our knowledge, published data on longitudinal follow-up of growth in pediatric patients with CKD is lacking from the region of South-East Europe. Herein we report the results from the Serbian Pediatric Registry of Chronic Kidney Disease.

METHODS

The data reported in the present prospective analysis were collected between 2000 and 2012. A total of 324 children with CKD were enrolled in the registry.

RESULTS

Prevalence of growth failure at registry entry was 29.3 %. Mean height standard deviation scores (HtSDS) in children with stunting and those with normal stature were -3.00 [95 % confidence interval (CI) -3.21 to -2.79] and -0.08 (95 % CI -0.22 to 0.05) (p < 0.001), respectively. Children with hereditary nephropathy had worse growth at registration (-1.51; 95 % CI -1.97 to -1.04, p = 0.008). Those with CKD stages 4 and 5 before registration had more chance to have short stature at registration than those with CKD stages 2 and 3 [odds ratio (OR) = 0.458, CI 0.268-0.782, p = 0.004]. Dialysis was an independent negative predictor for maintaining optimal stature during the follow-up period (OR = 0.324, CI = 0.199-0.529, p < 0.001), while transplantation was an independent positive predictor for improvement of small stature during follow-up (OR = 3.706, CI = 1.785-7.696, p < 0.001).

CONCLUSION

Growth failure remains a significant problem in children with CKD, being worst in patients with hereditary renal disease. Growth is not improved by standard dialysis, but transplantation has a positive impact on growth in children.

Combined NGS approaches identify mutations in the intraflagellar transport gene IFT140 in skeletal ciliopathies with early progressive kidney Disease

Ciliopathies are genetically heterogeneous disorders characterized by variable expressivity and overlaps between different disease entities. This is exemplified by the short rib-polydactyly syndromes, Jeune, Sensenbrenner, and Mainzer-Saldino chondrodysplasia syndromes. These three syndromes are frequently caused by mutations in intraflagellar transport (IFT) genes affecting the primary cilia, which play a crucial role in skeletal and chondral development. Here, we identified mutations in IFT140, an IFT complex A gene, in five Jeune asphyxiating thoracic dystrophy (JATD) and two Mainzer-Saldino syndrome (MSS) families, by screening a cohort of 66 JATD/MSS patients using whole exome sequencing and targeted resequencing of a customized ciliopathy gene panel. We also found an enrichment of rare IFT140 alleles in JATD compared with nonciliopathy diseases, implying putative modifier effects for certain alleles. IFT140 patients presented with mild chest narrowing, but all had end-stage renal failure under 13 years of age and retinal dystrophy when examined for ocular dysfunction. This is consistent with the severe cystic phenotype of Ift140 conditional knockout mice, and the higher level of Ift140 expression in kidney and retina compared with the skeleton at E15.5 in the mouse. IFT140 is therefore a major cause of cono-renal syndromes (JATD and MSS). The present study strengthens the rationale for IFT140 screening in skeletal ciliopathy spectrum patients that have kidney disease and/or retinal dystrophy.

Pulmonary renal syndrome in a child with coexistence of anti-neutrophil cytoplasmic antibodies and anti-glomerular basement membrane disease: case report and literature review

BACKGROUND

Pulmonary renal syndrome (PRS), denoting the presence of diffuse alveolar hemorrhage and glomerulonephritis as manifestations of systemic autoimmune disease, is very rare in childhood. The coexistence of circulating anti-neutrophil cytoplasmic antibody (ANCA) and anti-glomerular basement membrane (GBM) disease in children affected by this syndrome is exceptional, with unfavorable outcome in five out of seven patients reported to date. We describe a child with PRS associated with both circulating anti-myeloperoxidase (anti-MPO) ANCA and anti-GBM disease on renal biopsy who was successfully treated with immunosuppressive therapy.

CASE PRESENTATION

A 10-year old girl presented with fever, fatigue, malaise, and pallor followed by hemoptysis and severe anemia. Diffuse alveolar hemorrhage was revealed on fiberoptic bronchoscopy. Renal findings consisted of microscopic hematuria, moderate proteinuria, and anti-GBM disease on renal biopsy. ANCA with anti-MPO specificity were present whereas anti-GBM antibodies were on borderline for positivity. Methyl-prednisolone pulses followed by prednisone led to cessation of hemoptysis, marked improvement of lung fuction, and normal finding on chest x-ray within 10 days. An immunosuppressive regimen was then given consisting of prednisone daily for 4 weeks with subsequent taper on alternate day, i.v. cyclophosphamide pulses monthly for 6 doses, followed by mycophenolate mofetil that resulted in normal lung function tests, hemoglobin concentration, and anti-MPO level within four subsequent weeks. During 10-months of follow-up she remained well, her blood pressure and renal function tests were normal, and proteinuria and hematuria gradually resolved.

CONCLUSION

We report a child with an exceptionally rare coexistence of circulating ANCA and anti-GBM disease manifesting as PRS in whom renal disease was not the prominent part of clinical presentation, contrary to other reported pediatric patients. A review of literature on disease with double positive antibodies is also presented. Evaluation of a patient with PRS should include testing for presence of different antibodies. An early diagnosis and rapid institution of aggressive immunosuppressive therapy can induce remission and preserve renal function. Renal prognosis depends on the extent of kidney injury at diagnosis and appropriate treatment.

Reduced elastogenesis: a clue to the arteriosclerosis and emphysematous changes in Schimke immuno-osseous dysplasia?

BACKGROUND

Arteriosclerosis and emphysema develop in individuals with Schimke immuno-osseous dysplasia (SIOD), a multisystem disorder caused by biallelic mutations in SMARCAL1 (SWI/SNF-related, matrix-associated, actin-dependent regulator of chromatin, subfamily a-like 1). However, the mechanism by which the vascular and pulmonary disease arises in SIOD remains unknown.

METHODS

We reviewed the records of 65 patients with SMARCAL1 mutations. Molecular and immunohistochemical analyses were conducted on autopsy tissue from 4 SIOD patients.

RESULTS

Thirty-two of 63 patients had signs of arteriosclerosis and 3 of 51 had signs of emphysema. The arteriosclerosis was characterized by intimal and medial hyperplasia, smooth muscle cell hyperplasia and fragmented and disorganized elastin fibers, and the pulmonary disease was characterized by panlobular enlargement of air spaces. Consistent with a cell autonomous disorder, SMARCAL1 was expressed in arterial and lung tissue, and both the aorta and lung of SIOD patients had reduced expression of elastin and alterations in the expression of regulators of elastin gene expression.

CONCLUSIONS

This first comprehensive study of the vascular and pulmonary complications of SIOD shows that these commonly cause morbidity and mortality and might arise from impaired elastogenesis. Additionally, the effect of SMARCAL1 deficiency on elastin expression provides a model for understanding other features of SIOD.

Atypical presentation of cystic fibrosis--obese adolescent with hypertension and pseudo-Bartter's syndrome

INTRODUCTION

Infants with cystic fibrosis may fail to thrive despite recommended caloric intake because of electrolyte disurbances caused by salt depletion resulting in hypochloremic metabolic alkalosis or pseudo-Bartter's syndrome. In most patients reported symptoms began in infancy, but it may be an initial presentation of disease in a previously healthy adolescent.

CASE REPORT

A 15-year-old boy was admitted for evaluation of recurrent episodes of malaise associated with dehydration and acute renal insufficiency. Laboratory analysis showed hypochloremic metabolic alkalosis with hyponatremia and hypokalemia. On admission the boy was obese, with body weight of 95.5 kg (> P97), height 174 cm (> P75), and body mass index of 31.2 kg/m2 (> P95). Physical examination was inconclusive. Blood pressure holter monitoring proved significant systolic hypertension. Routine urinalysis, protein and electrolyte levels in urine were normal. Plasma renin and aldosteron were normal. Sweat chloride concentration was 63 mmol/L. Genetic testing confirmed the diagnosis of cystic fibrosis.

CONCLUSION

To our knowledge, this is the first reported case of atypical presentation of cystic fibrosis in an adolescent presented with pseudo-Bartter's syndrome and signs of obesity and hypertension. We suggest that every patient with hypochloremic metabolic alkalosis should be evaluated for cystic fibrosis.

Liddle syndrome in a Serbian family and literature review of underlying mutations

Severe and reproducible low-renin hypertension responsive to salt restriction and amiloride-thiazide therapy in a 13-year-old otherwise asymptomatic boy suggested Liddle syndrome. This assumption was strengthened by a positive family history of hypertension poorly responsive to conventional treatment or sudden deaths under 40 years of age in four generations. DNA analysis of the beta and gamma subunits of the epithelial sodium channel revealed a heterozygous mutation c.C1852T (p.Pro618Ser) in the SCNN1B gene in the patient and in both his hypertensive mother and uncle. A PubMed search revealed 21 different disease-causing mutations reported to date, all but two clustering in the cytoplasmic C-terminal regions of either beta (16 mutations) or gamma (5) subunit, leading to a three- to eightfold increase in the amiloride-sensitive sodium current. Inter- and intrafamilial variability in both hypertension and hypokalemia were disclosed, which may not be obligatory among the subjects carrying a Liddle mutation.

CONCLUSION

Liddle syndrome should be considered as a cause of hypertension in children or adolescents particularly with suppressed renin activity. Early diagnosis and appropriately tailored treatment avoid complications of long-term unrecognized or inappropriately managed hypertension.

Infantile nephropathic cystinosis

INTRODUCTION

Infantile nephropathic cystinosis (INC) is a metabolic disorder due to impaired carrier-mediated transport of cystine out of cellular lysosomes.

OBJECTIVE

To examine the prevalence and clinical characteristics of INC in paediatric patients with endstage renal disease (ESRD) in Serbia and give a recent statement of the disease.

METHODS

ESRD database of the Centre for Paediatric Renal Replacement Therapy (RRT) in Serbia was used to identify all patients with INC who started RRT before age of 19 years during the period January 1980 - December 2008; their records concerning clinical characteristics, therapy and outcome were evaluated.

RESULTS

Only three of 298 paediatric patients with ESRD had INC. The first signs of the illness were recognised during infancy. Fancony syndrome was diagnosed in the second year, but the diagnosis of cystinosis was delayed at mean 6 years. ESRD occurred in the first decade of life. All patients underwent cadaver kidney transplantation. At the end of the study period all patients were alive. A 31-year-old female patient was on maintenance chemodialysis due to graft failure after functioning for 11 years. She was growth retarded, single, unemployed, with severe signs of renal dystrophy. Two male patients (14.3 and 14.7 years old) had normal graft function, normal education, and good quality of life, although they were also severe growth retarded.

CONCLUSION

The prevalence of infantile nephropathic cystinosis is low in Serbia. The diagnosis of cystinosis was delayed in all patients, although they exhibited the typical course of the disease.

A novel CLCN5 mutation in a boy with Bartter-like syndrome and partial growth hormone deficiency

Dent disease is an X-linked recessive disorder affecting the proximal tubule and is characterized by low-molecular-weight proteinuria (LMWP), hypercalciuria, nephrocalcinosis/nephrolithiasis with a variable number of features of Fanconi syndrome. It is most often associated with mutations in CLCN5, which encodes the endosomal electrogenic chloride/proton exchanger ClC-5. Renal acidification abnormalities are only rarely seen in Dent disease, whereas the hypokalemic metabolic alkalosis associated with hyperreninemic hyperaldosteronism (Bartter-like syndrome) has been reported in only one patient so far. We report on a 5-year-old boy with Dent disease caused by mutation in CLCN5 gene, c.1073G>A, who presented with hypokalemic metabolic alkalosis and hyperreninemic hyperaldosteronism persisting over the entire follow-up. No mutations were found in NKCC2, ROMK, NCCT, or ClC-Kb genes. In addition, the patient exhibited growth failure associated with partial growth hormone (GH) deficiency. Coexistence of Bartter-like syndrome features with LMWP should prompt a clinician to search for Dent disease. The Bartter syndrome phenotype seen in Dent disease patients may represent a distinct form of Bartter syndrome, the exact mechanism of which has yet to be fully elucidated. Growth delay that persists in spite of appropriate therapy should raise suspicion of other causes, such as GH deficiency.

Henoch-Schönlein purpura nephritis in children: risk factors, prevention and treatment

AIM

To identify risk factors for a child with Henoch-Schönlein purpura (HSP) either to develop nephritis (HSPN) or to contract progressive course and to obtain the currently available evidence on the efficacy of treatment options in both preventing and treating the established renal disease.

METHOD

Review of the literature published over the last two decades.

RESULTS

Persistent or recurrent purpura, severe abdominal symptoms and an older age proved as the most significant risk factors for later HSPN. The risks of long-term renal impairment are the highest in children having at presentation nephritic/nephrotic syndrome and/or more than 50% of glomeruli occupied by large crescents or sclerosing lesions. Randomized controlled trials (RCT) do not support short course prednisone at presentation of HSP in preventing persistent renal disease. Many uncontrolled studies using various treatment regimens have reported outcomes considered better than expected. However, the data from RCTs are sparse and no treatment options for the established renal disease can be currently recommended based on RCTs.

CONCLUSION

Severity and/or duration of extrarenal HSP symptoms and an older age are the most significant risk factors for developing HSPN, whereas clinical and histological severity at HSPN onset are in general predictive of a long-term renal impairment. The existing evidence does not support of short course prednisone in preventing persistent renal disease. A well-designed RCTs are needed in children with moderately severe or rapidly progressive (crescentic) HSPN.

Diabetic nephropathy in children and adolescents

Type 1 diabetes mellitus (T1DM) commonly occurs in childhood or adolescence, although the rising prevalence of type 2 diabetes mellitus (T2DM) in these age groups is now being seen worldwide. Diabetic nephropathy (DN) develops in 15-20% of subjects with T1DM and in similar or higher percentage of T2DM patients, causing increased morbidity and premature mortality. Although overt DN or kidney failure caused by either type of diabetes are very uncommon during childhood or adolescence, diabetic kidney disease in susceptible patients almost certainly begins soon after disease onset and may accelerate during adolescence, leading to microalbuminuria or incipient DN. Therefore, all diabetics warrant ongoing assessment of kidney function and screening for the earliest manifestations of renal injury. Pediatric health care professionals ought to understand about risk factors, strategy for prevention, method for screening, and treatment of early DN. This review considers each form of diabetes separately, including natural history, risk factors for development, screening for early manifestations, and strategy recommended for prevention and treatment of DN in children and adolescents.

Lupus nephritis in childhood: a review of 53 patients followed at a single center

We retrospectively evaluated the clinical and histopathological features, treatment modalities, and outcome of 53 children and adolescents with biopsy-proven lupus nephritis (LN), followed between September 1983 and September 2001. The mean age (+/-SD) at the time of diagnosis of systemic lupus erythematosus (SLE) was 12.9+/-2.6 years and the mean follow-up from the time of biopsy was 4.8+/-3.4 years. At the time of biopsy, all 53 patients had proteinuria, 21 (40%) had nephrotic syndrome, and 14 (26%) had impaired renal function. Class IV nephritis, observed in 34 (64%) patients, was the most frequent histopathology on initial renal biopsy. The patients with class IV LN had a significant tendency to develop hypertension ( P=0.04) and nephrotic syndrome ( P=0.027), and a lower mean glomerular filtration rate ( P=0.000). Based on the renal histopathology and clinical presentation, patients were treated with corticosteroids alone or combined with azathioprine or with intravenous cyclophosphamide. Plasmapheresis or cyclosporine was used in 4 and 1 patient, respectively. Follow-up biopsies, performed in 13 patients, showed no change in 6 patients, were progressive in 4, and regressive in 3. On final clinical evaluation, renal disease was in complete or partial remission in 42 of 53 patients (80%), 4 had clinically active disease but with normal renal function, and 7 (13%), all with WHO class IV LN, were classified as having an adverse outcome, i.e., either preterminal (2) or terminal (4) renal failure or death (1). Five-year kidney and patient survival rates from the time of biopsy to the endpoints of terminal renal failure or death were 88.6% and 98.1%, respectively, in the whole group, and 82.4% and 97.1%, respectively, in the WHO class IV group. Nephrotic syndrome and class IV nephritis at initial biopsy were the only parameters significantly associated with adverse outcome in our study group. There was no association with gender, age, hypertension, impaired renal function, anemia, increased morphological index scores, and treatment modalities. We conclude that clinical and histopathological features of LN and treatment regimens in our study do not differ markedly from those in most pediatric series. However, the 5-year kidney and patient survival rates are among the best reported in recent pediatric series. The prognosis of LN is primarily dependent on the histopathological lesions.

[IgA nephropathy: clinico-morphologic correlations]

IgA nephropathy is glomerular disease characterized by the presence of IgA dominant or codominant immunoglobuline deposits in glomerular mesangium which can be demonstrated by immunofluorescence. Clinical manifestations of IgA nephropathy in the majority of cases is hematuria which can be macro or microscopic, isolated or combined with proteinuria, which can be of nephrotic range. The prognosis of the disease is better if presented with haematuria. Intensity of morphologic changes as well as the prognosis is in correlation with the amount of proteinuria. The prognosis is better in children.

Chronic renal failure (CRF) in children in Jugoslavia

The aim of this study was to analyse the demographic variables of chronic non-terminal (CRF) and terminal (TRF) renal failure patients (pts) younger than 19 years treated in Serbia in June 2001. The prevalence of CRF pts was registered as 4,7 per million total population (pmtp) or 14,1 per million child population (pmcp) while corresponding values for TRF pts were 4,5 pmtp or 13,5 pmcp. The incidence of TRF pts during the period Jan.2000-Jan.2002 was 4,35 pmcp. Boys dominated only among CRF pts (34:14); 60,4% beeing between the ages of 6 and 19 yrs while at the time of diagnosis of HBI, 33,3 % of boys were yanger than 2 yrs.The causes of CRF were: reflux nephropathy 58,3%, congenital kidney disease 16,7%, familial/hereditary 14,6% glomerulonephritis 6,2% and Willms tu 4,1%. Reflux nephropathy was also the most common underlying disease of TRF accounted for 36,9% of total cases while glomerulonephritis was responsible for 23,9 %. Reflux nephropathy was associated with neural tube defect in 53,3% and with congenital lower urinary tract obstruction in 66,7%. The most of CRF (81,25%) and TRF pts (95,6%) were from Serbia, the others were from Monte Negro and Republic Srpska. The most of CRF (65%) and TRF (80%) pts were treated in University Children?s Hospital in Belgrade. Of CRF pts 46% had serum sreatinine 100-200 ?mol/l, in 11% of pts it was 400-600 ?mol/l and 2% of pts were in pre-terminal CRF. One third of CRF pts had proteinuria 150-500 mg/l, and second third had proteinuria greater of 1000 mg/l. Anemia was present in 54% of CRf pts, and arterial hypertension in 56%. Hemodialysis was dominant treatment modality for TRF pts and only 23,9% had functioning transplant. Conclusion: This is the first national study of demographic characteristics of pediatric CRF in Serbia. Since its prevalence is considerably lower than that in Western and North European countries the true prevalence is some what higher. The increasing incidence of pediatric TRF from 2,85 pmcp to 4,35 pmcp reflect better diagnosis and treatment of these patients in the recent years.

Lupus nephritis: histopathologic features, classification and histologic scoring in renal biopsy

Lupus nephritis (LN) is one of the most significant manifestations in systemic lupus erythematosus (SLE), although in some cases there is no direct correlation among clinical, serologic and histologic findings. Therefore, renal biopsy and histopathologic classification by the activity and chronicity assessment of LN are considered necessary before the initiation of the treatment. In this paper 311 renal biopsies in patients with LN were analyzed and classified according to the WHO Classification published in 1974. Renal biopsy specimens were routinely processed for standard analysis by light microscopy (LM), immunofluorescent (IF), and electron microscopy (EM). Biopsy findings were compared with the common clinical symptoms. It is important to recognize that histopathologic lesions in the analyzed tissue might precede the symptoms and clinical manifestations, and therefore are an important factor in the appropriate therapeutic approach. Histopathological assessment of the class of LN represents an important predictor in most patients because the lesions of LN class I and class II most often have no progression and consequently do not require an aggressive treatment. Diffuse proliferative glomerulonephritis (class IV) as a severe form of renal lesion requires the application of high doses of corticosteroids and cytotoxic medicaments. The established quantitive indexes have significant predictive value. Activity index (AI) evaluates the presence of fresh inflammatory and potentially reversible lesions and chronicity index (CI) evaluate the presence of irreversible glomerular lesions such as sclerosis, tubular atrophy, interstitial fibrosis, etc. High AI and low CI, particularly in the class IV of LN, suggest the necessity of an aggressive treatment of the inflammatory process aiming to preserve the renal function. High CI and low AI characterize irreversible sclerosing lesions, where an aggressive treatment is considered unnecessary. Our experience suggests the necessity of introducing the new morphologic elements into the activity and chronicity scoring system which would correlate better the clinical symptoms. This should provide higher reliability of scoring, since it evaluates important elements in clinical-morphologic diagnosis of LN.

[Corticoid-sensitive nephrotic syndrome in children with myelodysplastic syndromes]

Several reports have documented various forms of glomerular diseases in adults with myelodysplastic syndromes (MDS), but similar reports in children are lacking. We describe two children with MDS-associated with steroid-responsive nephrotic syndrome (NS). Patient 1, who had MDS with myelofibrosis, presented also hepatosplenomegaly, pancytopenia, chronic hepatitis, moderate proteinuria, hypocomplementamia and elevated ANA titer. During initial prednisone treatment proteinuria markedly diminished and partial but transient haematological improvement occurred. Relapse subsequently occurred that was manifested by overt NS and pancytopenia. High doses of prednisolone led to remission of the renal disease but haematological remission did not occur. Persisting pancytopenia and repeated infections terminated in sepsis, two years after the onset of MDS. Patient 2, who had refractory anaemia with clonal monosomy 19, manifested bowel disease, hepatosplenomegaly, anaemia and non-organic specific autoantibodies. Prednisone led to both clinical and haematological remission. Haematologic disease relapsed 12 months later, when nephrotic-range proteinuria, haematuria and mild azotaemia were also found. Corticosteroid treatment led to long-lasting renal and haematologic remission, maintained by a small dosage of prednisone. In both patients, renal biopsy findings were consistent with those seen in idiopathic NS. A Medline search disclosed 16 cases of glomerulopathy in the course of MDS in adult patients. Clinical features included NS, usually accompanied by renal insufficiency with either acute, chronic, or rapidly progressive glomerulonephritis. On biopsy, membranous nephropathy, crescentic or mesangial proliferative glomerulonephritis and AL amyloidosis, were found. We conclude: (1) that glomerular disease may be present and should be searched for in patients with MDS; (2) that MDS can be added to the list of rare conditions associated with corticosteroid-responsive NS in children.

[Lupus nephritis in children and adolescents: clinical and morphologic aspects and clinico-morphologic correlations]

In 53 children and adolescents (47 males, 6 females) with lupus nephritis, clinical features at the time of renal biopsy were analyzed and correlated with pathohistological findings. The mean age at the time of diagnosis of systemic lupus was 12.9 +/- 2.6 (SD) years; the mean ages at the time of diagnosis of lupus nephritis and renal biopsy were 13.5 +/- 2.6 and 13.6 +/- 2.5 years, respectively. The most frequent clinical and laboratory features of lupus nephritis at the time of biopsy were proteinuria (100% of patients), haematuria (88%), nephrotic syndrome (38%), hypertension (32%), and decreased glomerular filtration rate (26%). On initial biopsy, the most frequent finding was diffuse proliferative glomerulonephritis (in 64.1%), followed by "mesangiopathy" (20.8%), minimal changes (7.5%), membranous nephropathy (5.8%), and focal proliferative nephritis (1.9%). Nephrotic syndrome, hypertension, decreased glomerular filtration rate, and haematuria were significantly associated with WHO classes IV and III of lupus nephritis.

[Lupus nephritis in children and adolescents: therapy, clinical course and prognosis]

In 53 children and adolescents (47 males, 6 females) with lupus nephritis, clinical features at the time of renal biopsy were analyzed and correlated with pathohistological findings. Therapeutic regimens used and the renal status at the end of follow-up are presented, and factors significantly associated with adverse outcome are analyzed. The mean age at the time of diagnosis of systemic lupus was 12.9 +/- 2.6 (SD) years, the mean ages at the time of diagnosis of lupus nephritis and renal biopsy were 13.5 +/- 2.6 and 13.6 +/- 2.5 years, respectively. The patients having WHO classes I and II of lupus nephritis were treated with prednisone and/or azathioprine; those with WHO classes IV and III were treated with cyclophosphamide (25) or with corticosteroids (5) or with corticosteroids and azathioprine (4), five of them were also treated with plasmapheresis; the patients with WHO class V were treated with prednisone and azathioprine or cyclosporine. Repeated renal biopsies were performed in 12 patients: worsening of morphological lesions was found in four patients, improvement in two and no change was observed in six patients (all with WHO class IV). At the end of follow-up lasting from 0.1 to 14.6 years (mean 4.8 +/- 3.2 years) 80% of patients were in complete (49%) or partial (30%) remission, in 8% of patients the renal disease was clinically active, and in 13% of patients the adverse outcome was noted: one patient died in the first month after diagnosis from extrarenal complications, two patients were in preterminal and the other four in terminal renal failure. Adverse outcome was significantly associated with the presence of nephrotic syndrome at the time of biopsy and with class IV nephritis. The five-year patient's survival rate was 98.1%. The five-year kidney survival rate was 88.6% and 82.4% for the whole group and for the subgroup of patients having classes III and IV nephritis, respectively.

Glomerular involvement in myelodysplastic syndromes

Several reports have documented various forms of glomerular diseases in adults with myelodysplastic syndromes (MDS), but similar reports in children are lacking. We describe two children with MDS-associated steroid-responsive nephrotic syndrome (NS). Patient 1, who had MDS with myelofibrosis, presented with hepatosplenomegaly, pancytopenia, chronic hepatitis, moderate proteinuria, hypocomplementemia and elevated ANA titer. During initial prednisone treatment proteinuria markedly diminished and partial but transient hematological improvement occurred. Relapse subsequently occurred that manifested by overt NS and pancytopenia. High doses of prednisolone led to remission of the renal disease, but hematological remission did not occur. Persisting pancytopenia and repeated infections terminated in sepsis, 2 years after the onset of the MDS. Patient 2, who had refractory anemia with clonal monosomy 19, presented with bowel disease, hepatosplenomegaly, anemia and non-organ-specific autoantibodies. Prednisone led to both clinical and hematological remission. The hematologic disease relapsed 12 months later, when nephrotic-range proteinuria, hematuria and mild azotemia were also found. Corticosteroid treatment led to long-lasting renal and hematologic remission, maintained by a small dosage of prednisone. In both patients, renal biopsy findings were consistent with those seen in idiopathic NS. A Medline search disclosed 16 cases of glomerulopathy in the course of MDS in adult patients. Clinical features included NS, usually accompanied by renal insufficiency with acute, chronic, or rapidly progressive glomerulonephritis. On biopsy, membranous nephropathy, crescentic or mesangial proliferative glomerulonephritis, and AL amyloidosis were found. We conclude: (1) that glomerular disease may be present and should be searched for in patients with MDS and (2) that MDS can be added to the list of rare conditions associated with corticosteroid-responsive NS in children.

[Schimke immuno-osseous dysplasia]

Schimke immuno-osseous dysplasia (OMIM *242900) is a rare autosomal recessive disorder that affects primarily the bone, the immune system, the kidneys, the skin and the vascular system. The patients have intrauterine growth retardation, short stature with short neck and trunk, peculiar clinical phenotype: triangular face, broad nasal bridge, bulbous nasal tip, small palpebral fissures, long upper lip and low hairline. The characteristic features include spondyloepiphyseal dysplasia, hyperpigmented maculae, proteinuria with progressive renal failure, lymphopenia with recurrent infections and cerebral ischaemia. We describe a girl, 5 years old, with short-trunk type of dwarfism (height 75 cm, below 3rd centile), short neck, accentuated lumbal lordosis and protruding abdomen. The patient had peculiar face with a broad, depressed nasal bridge, bulbous nasal tip, and slightly elongated upper lip. The hair was thin and sparse. Numerous pigmented spots resembling lentigines were visible on the trunk and abdomen. Radiographs showed spondyloepiphyseal dysplasia. At the age of 2 years laboratory analyses showed normal growth hormone secretion, normal thyroid function tests, normal female karyotype and no mucopolisachariduria. Since the age of 4 years, several episodes of transitory right-sided hemiparesis with spontaneous recovery, were observed. Seizures occurred at 5 years of age, when the MRI brain imaging showed multiple areas of ischaemia. She also experienced transient nephrotic syndrome, lymphopenia and low IgG accompanied by septicaemia.

[Acute tubulointerstitial nephritis in children]

Acute tubulointerstitial nephritis (ATIN) is a rare renal disorder in children. Patients usually present non-specific symptoms and signs so that the diagnosis of ATIN is often delayed. The disease may be infection- or drug-induced or it may occur without a known cause. Early recognition and appropriated therapy usually lead to an excellent prognosis. The aim of the study was to describe clinical and laboratory findings and the course of ATIN in 21 patients, that are typical enough to enable early recognition of the disease as it is potentially reversible.

METHODS

Between 1986 and 1997 we observed 21 patients, aged 7-16 years (mean, 12.8), with acute tubulointerstitial nephritis, including eight with tubulointerstitial nephritis and uveitis (TINU syndrome). Laboratory studies included urinalysis, complete blood count, erytrocyte sedimentation rate (ESR), plasma creatinine, glomerular filtration rate (GFR), electrolytes, proteins, IgG, C3, C4 antinuclear-antibodies (ANA), antistreptolysin-O and antibodies to hantaviruses. Renal ultrasound was done in all patients. Renal biopsy was performed in 5 children.

RESULTS

All children had previously been healthy. The symptoms of ATIN developed within a few days (Table 1). The most common initial symptoms were fatigue, fever, gastrointestinal disturbances, anorexia and weight loss. Less common complaints included headache, arthralgias and maculopapular rash. On addmition no patient had hypertension, oedema or evidence of acute infection. ESR, plasma urea and creatinine concentrations were increased in all, plasma proteins and IgG levels in the majority of patients. ANA were negative in 15 pts in whom this analysis was performed; C3 and C4 levels were normal. In two children recent strepococcal and in the other 6 hantavirus infection was serologicaly proved. All patients had non-oliguric acute renal failure (ARF): GFR was 21.7 +/- 8 9 in 14 pts and 67 +/- 9.7 in 7 pts. Low urine specific gravity (1003-1014), mild proteinuria (0.3-0.4 g/24 h), leukocyturia and/or haematuria were found in all patients; glycosuria, aminoaciduria and decreased tubular reaposrption of phosphate (TRP) were found in 12/21, 9/21 and 9/14 patients, respectively. Urine cultures were negative in all children. Renal US demonstrated enlarged hyperechoic kidneys in 11 pts, in remaining 10 pts no abnormalities were found. Renal biopsy, performed in 5 children, confirmed the diagnosis of ATIN. Eight patients subsequently developed anterior uveitis as part of TINU syndrome. Treatment included supportive therapy in all and six patients received prednisolone for 4-8 weeks (40-60 mg/m2/24 h for 10-14 days with subsequent reduction of dose over several weeks). Anterior uveitis was successfully treated with topical steroids. Renal function completely recovered in all patients: GFR (109 +/- 22.6 ml/min) within a mean interval of 47 +/- 33 days, concentration ability within 2-12 (mean 4.5) months.

DISCUSSION

Common clinical features of ATIN are non-oliguric acute renal failure of various degrees, signs of tubular dysfunction, proteinuria, haematuria, leukocyturia and absence of hypertension. All our patients had normal blood pressure, non-oliguric renal failure, proteinuria, hypostenuria and abnormal urinary sediment; about half of them had glycosuria and/or other signs of proximal tubular dysfunction. The most important causes of ATIN in children reported in literature are systemic infections and drugs. However, the cause of ATIN in our patients was assessed as being related to infection only in 8 patients and to diclofenac in one. No infection, drug, toxin or other cause could be identified in 4, as well as in 8 pts with TINU syndrome. The prognosis of ATIN in children is considered to be favourable, but some patients may develop chronic renal failure. Renal function completely recovered in all our patients; that is consistent with outcome data from the most reports.

CONCLUSION

Acute tubulointerstitial nephritis is an important cause of ARF in children, its aetiology may be different and it carries an excellent prognosis. ATIN should be suspected in a child who presents typical, although non-specific symptoms and signs, associated with lukocyturia and/or microhaematuria, signs of tubular dysfunction and unexplained renal failure. The diagnosis can be verified at renal biopsy. Early recognition of the disease is important to remove possible aetiologic agents and to treat them before chronic lesions are present to avoid long-term renal damage.

Interleukin-12 and interferon-gamma production in childhood idiopathic nephrotic syndrome

Cellular immune disturbances, and T lymphocyte function in particular, have been previously implicated in idiopathic nephrotic syndrome (INS) of childhood. There are different patterns of cytokine expression in various forms of glomerulonephritis, which suggests that local production of these peptides plays an important role in the pathogenesis and progression of glomerulonephritis. To investigate T-cell and monocyte/macrophage cytokine production in INS, interleukin-12 (IL-12) and interferon-gamma (IFN-gamma) production by peripheral blood mononuclear cells (PBMC) of 11 children with steroid-sensitive nephrotic syndrome (SSNS), 9 with focal segmental glomerulosclerosis (FSGS), and 17 healthy controls was determined. Children with SSNS were studied in relapse, during corticosteroid treatment, and in stable remission, off corticosteroid treatment. IL-12 was not detected in serum, urine, and in supernatants of unstimulated PBMC. IL-12 production by concanavalin A (Con A)-stimulated PBMC of children with SSNS and FSGS was not different from controls. IFN-gamma production by Con A-stimulated PBMC was decreased in children with relapsing SSNS, both in relapse and and during corticosteroid treatment. However, in stable remission it was similar to controls. Markedly decreased IFN-gamma production (P<0.001) was observed by pokeweed mitogen-stimulated PBMC of relapsing SSNS patients and moderately decreased production by PBMC of FSGS patients. This study has established a decreased production of IFN-gamma by PBMC of relapsing SSNS and FSGS patients, but does not allow differentiation between these two different conditions. IL-12 did not have a pathogenic role in either SSNS or FSGS.

Recurrent hemolytic uremic syndrome with hypocomplementemia and intestinal lymphangiectasia

A 23-year old male patient had eight distinct episodes of hemolytic uremic syndrome (HUS) between 8.5 and 15 years of age, five of them accompanied by hypocomplementemia. In the further course, severe hypertension, renal insufficiency as well as protein-losing enteropathy due to intestinal lymphangiectasia developed, whilst hypocomplementemia persisted. The association of recurrent HUS with hypocomplementemia and intestinal lymphangiectasia may represent a new association within a subgroup of the atypical HUS.

Shunt nephritis associated with Moraxella bovis

Moraxella bovis was repeatedly isolated from cerebrospinal fluid in a girl with two episodes of shunt nephritis. Clinical remission of nephritis was achieved only after shunt replacement. A list of about 20 infectious agents reported to date in patients with shunt nephritis is given. M. bovis is yet another agent previously not reported in patients with shunt nephritis.

[Shunt nephritis. 2 case reports and a review of the literature]

Two cases of glomerulonephritis associated with colonization of cerebrospinal fluid shunts inserted for the treatment of hydrocephalus (shunt nephritis) are described and additional 113 cases reported in world literature, are reviewed. Both of our patients were affected by two episodes of shunt nephritis. Complete clinical remission of renal disease followed antibiotic treatment in one patient, and shunt replacement combined with antibiotic therapy in the other. In the 115 cases of shunt nephritis reported to date, the causative organisms, clinical features, pathogenesis, renal histology, treatment, and outcome are discussed in detail. The importance of regular observation for early recognition of this reversible form of glomerulonephritis, is emphasized.

[Belgrade and Hantaan hantaviruses--the causative agents of haemorrhagic fever with renal syndrome in children in Serbia]

During an outbreak of haemorrhagic fever with renal syndrome (HFRS) in 1989, five children (3 girls, 2 boys, aged 6.8-16 years) with severe clinical form of the disease, were treated at the Institute of Mother and Child Health of Serbia; four of them were followed-up 22-28 months thereafter. The main clinical features were: fever, headache, myalgia, abdominal and back pains, and vomiting in all, and haemorrhagic syndrome in three; renal syndrome with severe acute renal failure in all five patients. All the patients recovered. Serological confirmation by an indirect immunofluorescence assay, enzyme immunoassay for IgM antibodies, and by plaque reduction neutralization test revealed that the infection was caused by Belgrade virus in three, and by Hantaan virus in two patients. It was not possible to differentiate these two serogroups on the basis of clinical features. This finding gave further evidence of circulation of different hantaviruses causing severe HFRS in Serbia.

[Acute tubulointerstitial nephritis with uveitis]

Clinical features and natural course of acute tubulointerstial nephritis and uveitis (TINU syndrome) in five adolescent patients (3 girls and 2 boys), are presented. Initial nonspecific symptoms preceding nephropathy were anorexia, weight loss, fever and malaise. Inflammatory syndrome consisted of increased ESR, high plasma proteins and gamma globulins. Analysis of urine showed proteinuria and sterile leukocyturia. Laboratory features of tubular dysfunction and decreased GFR were found in all patients. Renal biopsy, which was performed in 2 pts, revealed acute interstitial nephritis. Anterior uveitis which appeared later, was successfully treated with topical steroids. Renal function completely recovered within a few month in four pts and markedly improved in one. Despite the fact that renal biopsy was not performed in all children, the combination of an acute nonoliguric renal failure without hypertension and signs of tubular dysfunction together with particular benign course, suggested acute idiopathic TINU syndrome.

Belgrade and Hantaan hantaviruses--the causative agents of severe haemorrhagic fever with renal syndrome in children in Serbia

During an outbreak of haemorrhagic fever with renal syndrome (HFRS) in 1989, five children (3 girls, 2 boys, aged 6.8-16 years) with a severe form of the disease were treated; four of these were followed for 22-28 months. The main clinical features in all five patients were: fever, headache, myalgia, abdominal and back pain and vomiting; haemorrhagic syndrome was present in four children. Renal syndrome presented with severe acute renal failure in all five patients. All patients recovered. Serological confirmation by an indirect immunofluorescence assay, by enzyme immunoassay for IgM antibodies and by plaque reduction neutralization test showed infection by Belgrade virus in three and by Hantaan virus in two patients. It was not possible to differentiate these two serogroups on the basis of clinical features. This study provides further information on the circulation of different hantaviruses causing severe HFRS in Serbia.

[Lupus nephritis in children and adolescents (Part II: Prognosis)]

In 27 children and adolescents (24 females, 3 males suffering from lupus nephritis the important role of renal pathohistologic changes in the evolution and outcome of the disease was analysed, and a five-year survival rate was calculated. The mean age at the onset of the disease was 12.1 +/- 1.9 (range: 0.7-0) years, the mean interval from onset to renal biopsy was 2.1 +/- 1.9 (0.1 - 7.0) years, ant the mean follow-up was 4.1 +/- 2.1 (1-8) years. The pathohistologic changes were classified according to the World Health Organisation criteria. At the end of the follow-up patients classified in Ib and II classes were without urinary abnormalities, i.e. without preoteinuria and/or haematuria. However, patients in class IV manifests nephrotic syndrome (2 pts), renal failure (3 pts) or proteinuria and heamaturia (6 pts), and two patients died. More severe clinical features and course of lupus nephiritis associated with infavourable outcome significantly correlated with WHO classes III and IV. A five-year survival rate (life-table method) of 88.5% is among the best results reported to date in children and adolescents with lupus nephritis.

[Lupus nephritis in children and adolescents (clinical-morphologic correlation)]

Clinical and laboratory features in 27 children and adolescents (24 females, 3 males) with lupus nephritis were analysed and correlated with pathohistologic findings obtained by renal biopsy. The mean age at the onset of the disease was 12.1 +/- 1.9 (range 0.1-7.0) years. In the 30% of patients nephritis was one of the presenting features of the disease. The most frequent signs of the lupus nephritis at the time of biopsy were proteinuria (9 pts), proteinuria and haematuria (9 pts), and nephrotic syndrome (8 pts), while 7 patients showed decreased glomerular filtration rate (GFR), and hypertension was present in five. Distribution of patients according to the WHO morphologic classification of Lupus nephritis was as follows: 6 pts showed class Ib, 6 class II, 2 class III and 13 class IV. More severe renal dysfunction, manifested by nephrotic syndrome, proteinuria with haematuria, decreased GFR and hypertension was significantly associated with proliferative lupus nephritis (combined WHO classes III and IV). Nephrotic syndrome, haematuria and decreased serum C3 with significant probability predicted proliferative lupus nephritis, while decreased GFR was of borderline predictive value.

Focal glomerular sclerosis and nephrotic syndrome in spondyloepiphyseal dysplasia

The association of a spondyloepiphyseal dysplasia and disproportionate short stature with focal glomerular sclerosis is reported in two girls. Renal disease manifested by proteinuria at the age of 2.5 and 11 years, leading to treatment-resistant nephrotic syndrome over 15 and 45 months, respectively. One patient went into end-stage renal failure shortly after nephrotic syndrome developed, the other died from sepsis. The association of spondyloepiphyseal dysplasia and focal glomerular sclerosis with nephrotic syndrome may represent a distinct disease entity.

[Drug therapy of vesico-ureteral reflux in children]

The results of medical management of primary vesicoureteric refluc in 138 children aged 3 months to 15 years are presented. All children were kept on long-term, low-dose continuous chemoprophylaxis of urinary tract infection. During the 2-6 years follow-up period serial urine cultures, interval radiographic revaluation, renal function tests and blood pressure measurements were performed. Refluc disappeared spontaneously in 91 patients (66%), persisted in 9.4% and was later on surgically corrected in 20% of children. The refluc grade at presentation was the most important factor affecting the outcome: the refluc disappeared from 72% of affected ureters with grade I and II, and from 28% of ureters with grade III and IV. The presence of renal scaring and recurrence of urinary tract infection during the chemophylaxis did not influence the percentage of cured patients. Nevertheless, the mean duration of refluc from diagnosis to its spontaneous resolution was significantly longer in children with renal scars and urinary tract infections compared with its duration in children who had neither scars, nor further infections. Renal scarring progressed in 2.8% patients. Chronic renal failure developed, in spite of spontaneous resolution of refluc, in only one child with hypertension and bilateral renal scars at presentation. It is concluded that medical treatment of vesicoureteric refluc in most of the children is successful and in regard of preserving renal function stage.

Haemolytic-uraemic syndrome associated with Aeromonas hydrophila enterocolitis

Haemolytic-uraemic syndrome (HUS) associated with Aeromonas hydrophila enterocolitis is reported in a 23-month-old female infant. The A. hydrophila strain isolated from the patient's stool sample produced cytotoxin against verocells; increasing levels of cytotoxin-neutralizing antibody in the patient's sera were demonstrated, suggesting a recent infection. This report indicates that A. hydrophila should be suspected as a possible cause of HUS, and that this pathogen should be looked for in cases of post-diarrhoeal HUS.

Testicular function following cyclophosphamide treatment for childhood nephrotic syndrome: long-term follow-up study

Testicular function of 17 males treated in childhood or adolescence for nephrotic syndrome (NS) with cyclophosphamide (CY) for a mean time of 240 days (mean total dosage of 16.4 g or 641 mg/kg body weight) was evaluated at a mean time of 11.8 years after treatment. Five were azoospermic, 1 oligospermic, and 11 normospermic. There was a significant inverse correlation of sperm density with CY dosage and duration of treatment. All patients had undergone normal pubertal development and had normal sexual characteristics. Both basal and gonadotropin-releasing hormone-stimulated follicle-stimulating hormone (FSH) and luteinizing hormone (LH) concentrations were significantly raised in oligo- and azoospermic patients. Raised basal and peak FSH and LH concentrations in normospermic patients with a sperm count of less than 40 x 10(6)/ml were in keeping with impairment of two testicular components. However, mean basal plasma testosterone levels and mean peak plasma testosterone responses to human chorionic gonadotropin (HCG) did not differ significantly between patients and controls. Although LH responses to gonadotropin-releasing hormone suggested compensated Leydig cell failure in patients with testicular tubular damage, secretory reserve capacity of these cells, estimated by a HCG stimulation test, was preserved. Further follow-up is required to ascertain whether in these patients Leydig cell failure will develop with time.

Pituitary-gonadal function in women following cyclophosphamide treatment for childhood nephrotic syndrome: long-term follow-up study

Ovarian and pituitary-gonadal function was evaluated in 12 women who were treated with cyclophosphamide for nephrotic syndrome before or during puberty. The mean age at the start of treatment was 8.7 years; the mean total dose of cyclophosphamide was 439 mg/kg body weight; and the mean follow-up time was 12.3 years. The investigations included detailed developmental, menstrual and fertility histories; general and gynaecological examinations; basal levels and follicle-stimulating hormone and luteinizing hormone responses to gonadotropin-releasing hormone, and plasma oestradiol determinations. All patients had normal pubertal development and regular menstrual patterns. Two had borne healthy children. Although hormonal studies did not show obvious ovarian or pituitary-gonadal dysfunction, further follow-up is required to ascertain whether the patients with the most prolonged treatment undergo a premature menopause.

[Delayed effect of cyclophosphamide on testicular function after treatment of nephrotic syndrome in childhood]

The authors present the results of study of testicular spermatogenetic and endocrine function in adult males treated with high doses of cyclophosphamide for nephrotic syndrome during childhood and/or adolescence. Seventeen males, mean age of 22.5 years (range, 17-30) were examined after mean follow-up of 11.8 (5-17.3) years. Mean age at the time of treatment was 10.8 (3.6-17.6) years; mean duration of cyclophosphamide treatment was 240 (39-701) days, and mean total cumulative doses were 641 mg/kg body weight (103-1999) or 16.4 (3.9-55.7) grams. All the patients undergone normal pubertal development and had normal sexual characteristics. Eleven were normospermic (more than 20 x 10(6)/ml spermatozoa), one oligospermic and five azoospermic. There was a significant inverse correlations of sperm density with cyclophosphamide dosage and duration of treatment. These variables seem to be more important for cyclophosphamide toxicity, than stage of sexual development at time of treatment. Raised basal and stimulated FSH concentrations in oligoazoospermic patients were in keeping with impaired spermatogenesis. These patients had also raised basal and stimulated LH concentrations suggesting compensated Leydig cell failure. Subgroup of normospermic patients with lower spermatozoa concentrations (20-40 x 10(6)/ml) had significantly raised FSH and LH responses on stimulation with gonadotropin releasing hormone, suggesting dysfunction both tubular and interstitial cell component of the testis. In other normospermic patients gonadotropin responses were not different from controls. Basal and HCG stimulated testosterone concentrations showed no differences between patients and controls. These results confirmed significant inverse correlations of cyclophosphamide dosage with its effect on spermatogenesis, and documented the long-term effect on the Leydig cell function requiring further follow-up.

[Percutaneous biopsy of the kidney in children: indications, results, and complications]

The authors present results of systematic use of percutaneous renal biopsy in children in the first three years of practice. From 1986 to 1989, 153 renal biopsies were done in 144 children and adolescents (75 males, 69 females) aged 4 months to 18 years. The most common indications were as follow: primary nephrotic syndrome, most often resistant to corticosteroid treatment (28.5%), haematuria (28.5%), secondary glomerulopathies, either with or without nephrotic syndrome (9.7% and 15.3%, respectively), and proteinuria (4.9%). 90.8% of biopsies were successful obtaining adequate tissue for light microscopic diagnosis, containing a n average number of 16 glomeruli. An overall number of 29 complications (18.9% of biopsies) in 23 patients was observed. Gross haematuria was the most common, lasting no more then one (9.8% of biopsies) or three days (2.6%) requiring blood transfusions in three cases (1.96% of biopsies). Others complications were fever (1.96%), perirenal haematoma (1.3%), and severe pain at the site of biopsy (1.3%). There were no significant differences between three annual periods with regard to the incidence of successful biopsies or complications, but more serious complications occurred during the first year of practice. In children younger than five years the rate of successful biopsies was higher and incidence of complications was lower than in older children. The authors' results correlate favourably with data published in the foreign literature.

Recurrent haemolytic-uraemic syndrome with hypocomplementaemia: a case report

A boy who developed haemolytic-uraemic syndrome (HUS) at 8 years 6 months of age had four further episodes of the disease during the next 3 years. No renal abnormalities were detected between the attacks nor in the 2.5 years after the last recurrence. Reduced levels of serum complement were found during four of the episodes and in two intervening periods.