Prevalence and Mortality of Post-traumatic Acute Kidney Injury in Children; a Systematic Review and Meta-analysis

Introduction

Numerous studies on acute kidney injury (AKI) following trauma have been performed, and acceptable findings have been reported in the adult population. The present meta-analysis summarizes the studies performed on the pediatric population to evaluate the prevalence of AKI following trauma in this population.

Method

The Medline, Embase, Scopus and Web of Sciences databases were searched for articles published until the July, 31, 2021. Two independent reviewers screened observational studies performed on children with physical trauma and AKI related to it. The interested outcomes were the prevalence and mortality of trauma-related AKI in traumatized children.

Results

Data of 9 articles were included in the present meta-analysis. The prevalence of trauma-related AKI varied between 0% and 30.30% among included studies. Pooled analysis showed that the prevalence of trauma-related AKI was 9.86% (95% CI: 8.02 to 11.84%). The prevalence of AKI after exertional rhabdomyolysis, direct physical trauma, and earthquake related injuries was 0%, 12.64% and 24.60%, respectively. There was a significant relationship between the prevalence of AKI and trauma etiology (p = 0.038). Moreover, the occurrence of AKI in children with trauma was associated with an increased risk of mortality (OR = 5.55; 95% CI: 2.14 to 13.93).

Conclusion

The findings of the present study showed that 9.86% of children develop AKI following trauma, which may increase their risk of death by about 5.5 times. Nevertheless, since none of the studies had adjusted their analyzes for potential confounders, caution should be exercised in interpreting the relationship between trauma-related AKI and mortality.

Assessing the value of serum and urinary interleukins for diagnosis of acute kidney injury in children and adolescents: A systematic review and meta-analysis

Introduction

Method

Results

Conclusion

•

Urinary level of IL-18 is significantly higher in AKI children in comparison with non-AKI children.

•

Serum levels of IL-6 and IL-8 are significantly higher in AKI children in comparison with non-AKI children.

•

Overall, the sensitivity and specificity of these markers are not desirable for diagnosing AKI.

•

Future studies should be directed towards unifying cut-off points for these markers.

Chronic Kidney Disease in Iran: First Report of the National Registry in Children and Adolescences

PURPOSE

Knowing the epidemiological aspects of chronic kidney disease (CKD) in children is crucial for early recognition, identification of reversible causes, and prognosis. Here, we report the epidemiological characteristics of childhood CKD in Iran.

MATERIALS AND METHODS

This cross-sectional study was conducted during 1991 - 2009. The data were collected using the information in the Iranian Pediatric Registry of Chronic Kidney Disease (IPRCKD) core dataset.

RESULTS

A total of 1247 children were registered. The mean age of the children at registration was 0.69 ± 4.72 years (range, 0.25 -18 years), 7.79 ± 3.18 years for hemodialysis (HD), 4.24 ± 1.86 years for continuous ambulatory peritoneal dialysis (CAPD), and 3.4±1.95 years for the children who underwent the renal transplantation (RT) (P < .001). The mean year of follow-up was 7.19 ± 4.65 years. The mean annual incidence of CKD 2-5 stages was 3.34 per million age-related population (pmarp). The mean prevalence of CKD 2-5 stages was 21.95 (pmarp). The cumulative 1-, 5-, and 10-year patients' survival rates were 98.3%, 90.7%, and 84.8%, respectively. The etiology of the CKD included the congenital anomalies of the kidney and urinary tract (CAKUT) (40.01%), glomerulopathy (19.00%), unknown cause (18.28%), and cystic/hereditary/congenital disease (11.14%).

CONCLUSION

The incidence and prevalence rate of pediatric CKD in Iran is relatively lower than those reported in Europe and other similar studies. CAKUT was the main cause of the CKD. Appropriate management of CAKUT including early urological intervention is required to preserve the renal function. Herein, the long-term survival rate was higher among the children with CKD than the literature.

Age-Period-Cohort Analysis of Abdominal Obesity in Iranian Children and Adolescents: The CASPIAN Study

BACKGROUND

The assessment of the trend of changes in the prevalence of abdominal obesity can provide useful health information.

OBJECTIVES

This study aimed to conduct an age-period-cohort (APC) analysis to provide the trend of the prevalence of abdominal obesity in the Iranian pediatric population through the three temporal dimensions of age, period, and cohort.

METHODS

Data were gathered from a total number of 53,962 Iranian children and adolescents aged 5 to 19 years through four surveys of a national surveillance program (the CASPIAN study) conducted in 2003, 2007, 2011, and 2015. Abdominal obesity was defined as a waist-to-height ratio of ≥ 0.5. The APC analysis was performed using the "apc_ie"command in STATA software.

RESULTS

A significant correlation existed between age, period, and cohort effects and the prevalence of abdominal obesity in children and adolescents. With increasing age, regardless of considerable fluctuations, the prevalence of abdominal obesity followed an overall increasing trend in both genders. The age effect coefficient increased from -2.1 in the age group of 5 - 9 years to 1.1 in the age group of 10 - 14 years and then decreased to 1.0 in the age group of 15 - 19 years among boys; figures followed an increasing trend in girls from -2.2 to 0.8 and 1.5, respectively. As for the period effect, in both boys and girls, the prevalence of abdominal obesity followed an increasing trend when coming from the earlier periods to the recent ones (from -4.6 to 4.0 in boys and from -4.1 to 2.4 in girls). Likewise, this prevalence increased from earlier birth cohorts to the recent ones in both genders.

CONCLUSIONS

The prevalence of abdominal obesity is increasing among Iranian children and adolescents and this rising trend is affected by age, period, and birth cohort effects. The findings of this study emphasize the necessity of implementing comprehensive interventions for tackling the epidemic of childhood obesity.

The efficacy of probiotics in prevention of urinary tract infection in children: A systematic review and meta-analysis

BACKGROUND

A consensus has not been reached yet about the efficacy of probiotics in reducing the incidence of urinary tract infections (UTIs) in children. This systematic review and meta-analysis was designed to assess the efficacy of probiotics in prevention UTI in children.

METHODS

The present study was designed based on guidelines for systematic reviews of clinical trials. Two independent reviewers performed an extensive search in the Medline, Embase, Web of Science and Scopus electronic databases up to the end of 2016. The summery of eligible studies was assessed independently by two reviewers and recorded in the data extraction form. Finally, a pooled relative risk (RR) was reported with a 95% confidence interval (95% CI).

RESULTS

Data from 10 studies were entered in the present meta-analysis. Probiotic therapy did not have any beneficial effect on the incidence of UTI (RR = 0.94; 95% CI 0.85-1.03; p = 0.19) and its recurrence (RR = 0.93; 95% CI 0.85-1.02; p = 0.14). Subgroup analyses showed that probiotics as monotherapy do not have any beneficial effects on prevention of UTI (RR = 0.96; 95% CI 0.89-1.04; p = 0.31). However, the incidence of UTI is reduced if probiotics are used as adjuvant therapy to antibiotics (RR = 0.92; 95% CI 0.85-0.99; p = 0.02).

CONCLUSION

The present meta-analysis showed that probiotics did not have a beneficial effect in reducing the incidence or recurrence of UTI. Only a moderate efficacy was seen when a probiotic was used as adjuvant therapy to antibiotics.

Age-Period-Cohort Analysis of Obesity and Overweight in Iranian Children and Adolescents

BACKGROUND

To date, few studies looked upon obesity and overweight in children and adolescents through the 3 different temporal dimensions of age, period, and cohort. The current study aimed at evaluating the trends of these health issues among children under 19 years old using the age-period-cohort (APC) analysis.

METHODS

Data gathered through 5 cross sectional studies including 2 national health surveillance (1990 - 91 and 1999), and 3 CASPIAN surveys (2003, 2009, and 2011). Subjects were classified by their body mass index (BMI) into 3 groups of normal (BMI < 85th percentile), overweight-obese (85th percentile < BMI < 95th percentile), and obese (95th percentile < BMI). Intrinsic estimator method was used to analyze the effects of age, period, and birth cohort on obesity and overweight among the subjects.

RESULTS

A total of 80,698 children and adolescents under 19 years old, including 40,419 (50.09%) males and 40,279 (49.91%) females, were evaluated. The prevalence of obesity decreased progressively by age in males and females with minor discrepancies. It increased from 1990 to 2009 in both genders, but from that point on remained quite constant in males and dropped significantly in females. The prevalence of obesity was steady in earlier birth cohorts, but increased significantly after the birth cohorts from 1986 to 1990.

CONCLUSIONS

Environmental factors and social stresses during neonatal and infantile periods (birth cohort effect) along with other variables influencing the children later in their lives (period effect) affect the prevalence of overweight and obesity substantially. Moreover, a decrease in the prevalence of obesity and overweight was observed by age increase (age effect).

Zero and Five End-Digit Preference and Blood Pressure Quality of Care Revisited

BACKGROUND

To determine the rate of zero and five end-digit preference (EDP) for systolic and diastolic blood pressures (SBP and DBP, respectively) and risk factors amongst a representative sample of Iranian adults in the year 2011.

METHODS

Data gathered from 7997 Iranian adults aged 25-70 were extracted from the database of the sixth Survey of Surveillance of Risk Factors of Non-communicable Diseases, which surveyed a total of 11,864 individuals aged 6 to 70 years. Multilevel multiple logistic regression was used to identify the independent factors associated with zero or five EDP.

RESULTS

The prevalence of three serial zero or five EDP for SBP and DBP were 18.5% (95% CI: 11.3%-25.7%). SBP ≥140 mmHg (OR = 0.78; 95% CI: 0.65-0.95), DBP ≥90 mmHg (OR = 0.71; 95% CI: 0.58-0.88), and a positive family history of diabetes (OR = 0.77; 95% CI: 0.66-0.9) were found as protective factors against zero or five EDP in blood pressure recording the male gender (OR = 1.18; 95% CI: 1.04-1.35) was found to be its independent risk factor.

CONCLUSION

Sex, SBP, DBP and family history of diabetes were found to be the main independent determinants of EDP in our country which underscores the importance of assessing the many patient-related factors in the studies involving EDP as part of BP monitoring in public health care.

Neck Circumference Percentiles of Iranian Children and Adolescents: The Weight Disorders Survey of CASPIAN IV Study

BACKGROUND

Neck circumference (NC), emerging as a key morphological index for pediatric obesity, is associated with obesity- and overweight-related detrimental conditions in children. In this study, we aimed to provide the age- and sex-specific percentile reference values for neck circumference of the Iranian children and adolescents.

METHODS

We used the data gathered through the weight disorders survey of CASPIAN IV study conducted in 2011 - 2012 in Iran, including a total of 21954 Iranian children and adolescents, composed of 10750 girls and 11204 boys, aged 7 - 18 years old. We presented the interval of NC percentile in three age groups of 7 - 10 years, 11 - 14 years, and 15 - 18 years. Finally, age-specific nomograms of NC for both genders in the Iranian and Canadian populations were compared.

RESULTS

The intervals of 90th percentile of NC for boys in the three periods of school age (7 - 10 years), pre-adolescence (11 - 14 years), and adolescence (15 - 18 years) were 24.2 - 30.0 cm, 26.6 - 33.2 cm, and 30.1 - 38.5 cm, respectively. These intervals for girls were 23.7 - 30.1 cm, 26.5 - 33.7 cm, and 28.5 - 36.0 cm, respectively. NC increased with age in both boys and girls and its variability showed an increasing trend with age.

CONCLUSIONS

We demonstrated for the first time the NC reference values for the Iranian children and adolescents aged 7 - 18 years old. Considering the significant differences between our national NC references and the values reported from the Canadian population, it seems logical to use these national percentiles not only for epidemiologic studies but also for routine clinical examinations.

Angiotensin-Converting Enzyme Gene Polymorphism in Children with Idiopathic Nephrotic Syndrome, Effect on Biopsy Findings

OBJECTIVE

Angiotensin converting enzyme (ACE) converts angiotensin I into angiotensin II. The ACE gene shows an I/D polymorphism, which correlates with ACE concentrations. The aim of this study is to evaluate the distribution of the ACE I/D genotype in children with idiopathic nephrotic syndrome (INS) and healthy controls and study the effect of this polymorphism on clinical and pathologic findings.

METHODS

ACE gene I/D polymorphism of 104 patients with INS and 119 controls were determined.

RESULTS

The DD, ID, and II genotypes were found in 58.7%, 22.1%, and 19.2% of the patients, and in 79.8%, 2.5%, and 17.6% of controls, respectively (p > 0.05). The ID genotype was seen more frequently in patients resistant to treatment.

CONCLUSION

The observed differences with previous reports suggest the influence of the genetic background on disease course. The ACE I/D gene polymorphism's role seems to be more important in renal disease progression than susceptibility.

Accuracy of cystatin C in prediction of acute kidney injury in children; serum or urine levels: which one works better? A systematic review and meta-analysis

BACKGROUND

There is still an ongoing discussion on the prognostic value of cystatin C in assessment of kidney function. Accordingly, the present study aimed to conduct a meta-analysis to provide evidence for the prognostic value of this biomarker for acute kidney injury (AKI) in children.

METHODS

An extensive search was performed in electronic databases of Medline, Embase, ISI Web of Science, Cochrane library and Scopus until the end of 2015. Standardized mean difference (SMD) with a 95% of confidence interval (95% CI) and the prognostic performance characteristics of cystatin C in prediction of AKI were assessed. Analyses were stratified based on the sample in which the level of cystatin C was measured (serum vs. urine).

RESULTS

A total of 24 articles were included in the meta-analysis [1948 children (1302 non-AKI children and 645 AKI cases)]. Serum (SMD = 0.96; 95% CI: 0.68-1.24; p < 0.0001) and urine (SMD = 0.54; 95% CI:0.34-0.75; p < 0.0001) levels of cystatin C were significantly higher in children with AKI. Overall area under the curve of serum cystatin C and urine cystatin C in prediction of AKI were 0.83 (95% CI: 0.80-0.86) and 0.85 (95% CI: 0.81-0.88), respectively. The best sensitivity (value = 0.85; 95% CI: 0.78-0.90) and specificity (value = 0.61; 95% CI: 0.48-0.73), were observed for the serum concentration of this protein and in the cut-off points between 0.4-1.0 mg/L.

CONCLUSION

The findings of the present study showed that cystatin C has an acceptable prognostic value for prediction of AKI in children. Since the serum level of cystatin C rises within the first 24 h of admission in patients with AKI, this biomarker can be a suitable alternative for traditional diagnostic measures.

Height-adjusted percentiles evaluated central obesity in children and adolescents more effectively than just waist circumference

AIM

We compared the prevalence of obesity based on both waist circumference for height and body mass index (BMI) in Iranian children and adolescents.

METHODS

Data on 13 120 children with a mean age of 12.45 ± 3.36 years (50.8% male) from the fourth Childhood and Adolescence Surveillance and Prevention of Adult Non-communicable Disease study were included. Measured waist circumference values were modelled according to age, gender and height percentiles. The prevalence of obesity was estimated using the 90th percentiles for both unadjusted and height-adjusted waist circumferences and compared with the World Health Organization BMI cut-offs. They were analysed further for short, average and tall children.

RESULTS

Waist circumference values increased steadily with age. For short and average height children, the prevalence of obesity was higher when height-adjusted waist circumference was used. For taller children, the prevalence of obesity using height-adjusted waist circumference and BMI was similar, but lower than the prevalence based on measurements unadjusted for height. Height-adjusted waist circumference and BMI identified different children as having obesity, with overlaps of 69.47% for boys and 68.42% for girls.

CONCLUSION

Just using waist circumference underestimated obesity in some Iranian children and measurements should be adjusted for height.

A treatment algorithm for children with lupus nephritis to prevent developing renal failure

Chronic kidney disease is one of the most common complication of systemic lupus erythematosus, which if untreated can lead to the end-stage renal disease (ESRD). Early diagnosis and adequate treatment of lupus nephritis (LN) is critical to prevent the chronic kidney disease incidence and to reduce the development of ESRD. The treatment of LN has changed significantly over the past decade. In patients with active proliferative LN (Classes III and IV) intravenous methylprednisolone 1 g/m2/day for 1-3 days then prednisone 0.5-1.0 mg/kg/day, tapered to <0.5 mg/kg/day after 10-12 weeks of treatment plus mycophenolate mofetile (MMF) 1.2 g/m2/day for 6 months followed by maintenance lower doses of MMF 1-2 g/day or azathioprine (AZA) 2 mg/kg/day for 3 years have proven to be efficacy and less toxic than cyclophosphamide (CYC) therapy. Patients with membranous LN (Class V) plus diffuse or local proliferative LN (Class III and Class IV) should receive either the standard 6 monthly pulses of CYC (0.5-1 g/m2/month) then every 3(rd) month or to a shorter treatment course consisting of 0.5 g/m2 IV CYC every 2 weeks for six doses (total dose 3 g) followed by maintenance therapy with daily AZA (2 mg/kg/day) or MMF (0.6 g/m2/day) for 3 years. Combination of MMF plus rituximab or MMF plus calcineurin inhibitors may be an effective co-therapy for those refractory to induction or maintenance therapies. This report introduces a new treatment algorithm to prevent the development of ESRD in children with LN.

Early detection of acute kidney injury by serum cystatin C in critically ill children

BACKGROUND

We prospectively evaluated whether serum cystatin C (CysC) detected acute kidney injury (AKI) earlier than basal serum creatinine (Cr).

METHODS

In 107 pediatric patients at high risk of developing AKI, serum Cr and serum CysC were measured upon admission. Baseline estimated creatinine clearance (eCCl) was calculated using a CysC-based glomerular filtration rate (GFR) equation from a serum Cr measured at the pediatric intensive care unit (PICU) entrance.

RESULTS

The median age was 10 months (interquartile range, 3-36 months). Serum Cr, serum CysC, and eCCl (mean ± standard deviation [range]) were 0.5 ± 0.18 mg/dl (0.2-1.1 mg/dl), 0.53 ± 0.78 (0.01-3.7 mg/l), and 72.55 ± 28.72 (20.6-176.2) ml/min per 1.73 m(2), respectively. The serum CysC level in patients with AKI was significantly higher than children with normal renal function (p < 0.001). The values for the cut-off point, sensitivity, specificity, and the area under curve (AUC) were determined for CysC as 0.6 mg/l, 73.9 %, 78.9 %, and 0.92 [95 % confidence interval (0.82-1)], respectively, and for Cr the values were 0.4 mg/dl, 68 %, 46.2 %, and 0.39, [95 % confidence interval (0.24-0.54)], respectively. The receiver operating characteristics (ROC) curve analysis revealed that CysC had a significantly higher diagnostic accuracy than eCCl (p < 0.001).

CONCLUSIONS

Our results identify that the sensitivity of serum CysC for detecting AKI is higher than that of serum Cr in a heterogeneous pediatric intensive care unit (PICU) population.

Weight, height and body mass index nomograms; early adiposity rebound in a sample of children in tehran, iran

BACKGROUND

Assessing growth is a useful tool for defining health and nutritional status of children. The objective of this study was to construct growth reference curves of Iranian infants and children (0-6 years old) and compare them with previous and international references.

METHODS

Weight, height or length of 2107 Iranian infants and children aged 0-6 years old were measured using a cross-sectional survey in Tehran in 2010. Standard smooth reference curves for Iranian population were constructed and compared to multinational World Health Organization 2006 reference standards as well as a previous study from two decades ago.

RESULTS

Growth index references for Iranian girls are increased in compare to data from two decades ago and are approximately close to the international references. In boys; however, the increment was considerably large as it passed the international references. Not only the values for indexes was changed during two decades, but also the age at adiposity rebound came near the age of 3, which is an important risk factor for later obesity.

CONCLUSIONS

During two decades, growth indexes of Iranian children raised noticeable. Risk factors for later obesity are now apparent and demand immediate policy formulations. In addition, reference curves presented in this paper can be used as a diagnostic tool for monitoring growth of Iranian children.

Incidence of urinary tract infection in neonates with septicemia: a prospective study

AIM

The aim of this study was to investigate the incidence and clinical course of urinary tract infection (UTI) in neonates with septicemia and also determine the most common UTI manifestations in hospitalized neonates.

METHODS

A cross-sectional study was carried out on consecutive febrile infants aged 1 to 56 days that were hospitalized in the neonatal intensive care unit. In all neonates with positive urine culture, scintigraphy with technetium-99m-labeled dimercaptosuccinic acid (DMSA) and ultrasonography (US) were performed. Voiding cystourethrography was performed in the course of the illness, generally within 5-7 days of hospitalization.

RESULTS

Positive blood culture was detected only in 9% of patients. However, 5% of them had positive urine culture. Positive abnormal US findings were present in two of five (40%) and vesicoureteral reflux (VUR) was present in one of five (20%) of infants with positive urine culture.

CONCLUSION

DMSA scan revealed renal parenchymal abnormalities in 3 of 5 (60%) neonates with urosepsis. The incidence of UTI in neonates with septicemia is low. All neonates with sepsis and positive urine culture should undergo a screening renal scintigraphy and cystogram for identifying renal parenchymal involvement and urinary tract abnormalities.

Clinical course and outcome of children with steroid-sensitive nephrotic syndrome

We conducted a retrospective study on children with primary nephrotic syndrome (NS) to evaluate the clinical course and outcome of children with steroid-sensitive NS (SSNS). The medical records of 226 children, median 3.46 years (min 1.00, max 15.08) who referred to our clinics with SSNS between January 1978 and September 2005 were reviewed and entered into the study. Minimum duration of follow-up was 5 years and maximum 20 years (median 7.25 years). Of 226 patients who were treated with corticosteroids, 38 (16.8%) had no relapse but the remaining 188 (83.2%) patients experienced several relapses of which 128 patients (56.6%) required additional immunosuppressive agents for the remission. Of these, 122 (95%) were treated with levamisole, 22 (17%) with cyclosporine, 36 (28%) with cyclophosphamide, and ten (7.8 %) treated with mycophenolate mofetil. Several patients had to switch from one medication to others due to lack of response. On the last follow-up visit, 64(28.3%) patients were still under treatment, some patients had taken all of the above-mentioned drugs but still had multiple recurrences. Only 103 (45.5%) patients were in remission off the drug more than 3 years. This study shows that nearly one-third of pediatric patients with SSNS experience frequent relapses despite the combination of multiple immunosuppressive medications, which may continue until adulthood.

The relation of body mass index and blood pressure in Iranian children and adolescents aged 7-18 years old

BACKGROUND

The obesity and hypertension are the major risk factors of several life threatening diseases. The present study was aimed to investigate the relation between body mass index (BMI) the validated index of adiposity and different aspect of blood pressure (BP).

METHODS

Systolic and diastolic blood pressures and also weight and height of 7 to 18 years old children and adolescent collected in 2002 and 2004 respectively. Data was consisted of 14865 schoolchildren and adolescents from representative sample of country. BMI was classified according to CDC 2000 standards into normal (BMI<85th percentile), at risk of overweight (BMI≥85th and <95th percentile) and overweight (BMI≥95th percentile). Then, age-sex specific prevalence of being overweight was derived. ANOVA was used to investigate the effect of BMI on systolic blood pressure and diastolic blood pressure and mean arterial pressure of participants.

RESULTS

Mean systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial blood pressure (MAP) significantly increased with BMI (P< 0.0001) and age groups (P< 0.0001), and was significantly (P< 0.0001) higher in boys than girls especially in older ages. (P< 0.0001, interaction of age and BMI level). The proportion of being overweight was significantly higher in boys than girls was (7.4% vs. 3.6%; P< 0.0001).

CONCLUSION

There is an association between BP and BMI in children and adolescence. SBP, DBP and MAP are associated with rise in BMI and age, which was lower in girls. This data can provide basics for public health policy makers and primary prevention policies in the country.

Incidence of urinary tract infection in neonates with septicemia: a prospective study

AIM

The aim of this study was to investigate the incidence and clinical course of urinary tract infection (UTI) in neonates with septicemia and also determine the most common UTI manifestations in hospitalized neonates.

METHODS

A cross-sectional study was conducted on consecutive febrile infants aged 1 to 56 days that were hospitalized in the neonatal intensive care unit. In all neonates with positive urine culture, scintigraphy with technetium-99m -labeled dimercaptosuccinic acid (DMSA) and ultrasonography (US) were done. Voiding cystourethrography was performed in the course of the illness, generally within 5-7 days of hospitalization.

RESULTS

Positive blood culture was detected only in 9% of patients. However, 5% of them had positive urine culture. Positive Abnormal US findings were present in 2 of 5 (40%) and vesicoureteral reflux (VUR) was present in 1 of 5 (20%) of infants with positive urine culture.

CONCLUSION

DMSA scan revealed renal parenchymal abnormalities in 3 of 5 (60%) neonates with urosepsis. The incidence of UTI in neonates with septicemia is low. All neonates with sepsis and positive urine culture should undergo a screening renal scintigraphy and cystogram for identifying renal parenchymal involvement and urinary tract abnormalities.

Ultrasonographic diagnosis of urinary tract anomalies in neonates: a study among Iranian children

AIM

The incidence of urinary tract anomalies varies in different population and depends on several factors such as underlying etiologies. The goal of this study was to investigate the incidence of abnormal urinary tract ultrasound findings in children with different etiologies.

METHODS

In a case-series study, 100 neonates who were hospitalized in the Children's Hospital Medical Center with the different etiologies such as sepsis, icter, seizure, and respiratory distress were included. In all neonates, ultrasound study was performed by using 3.5-7.5 MHz probe and neonates with the diagnosis of urinary tract infection underwent DMSA scan and voiding cystourethrogram (VCUG).

RESULTS

The mean age of neonates was 10.15+/-7.45 days and 56% of patients were male. The most frequent etiologies led to hospitalization were icter (37%), sepsis (35%), and infectious respiratory distress (10%). Abnormal sonographic findings were found in 5% of patients. The frequency of urinary tract anomalies in neonates with sepsis was higher than non-septic group (14.29% versus 0.0%, P=0.008).

CONCLUSION

The incidence of urinary tract anomalies which detected by sonography in our population is higher than other reported studies and has strong relationship with the occurrence of neonatal sepsis.

The relationship of body mass index and blood pressure in Iranian children <7 years old

The objective of this study was to evaluate the association between the body mass index (BMI), in healthy young children with their blood pressure (BP). The study included 3186 healthy children aged 1-6 years who were studied between March 2004 and March 2007 in different kindergartens and health centers in Tehran. Each child was classified on the basis of age- and sex-specific BMI percentile as normal weight (BMI <85th percentile), at risk for overweight (BMI >85th and <95th percentile), or overweight (BMI > or =95th percentile). Systolic BP (SBP) and diastolic BP (DBP) was compared among age-sex-BMI groups. Among children aged below 7 years in kindergartens and health centers in Tehran, 7.2% were at risk of overweight and 12.2% were overweight. These proportions were similar for boys and girls and were as follows: 6.9%, 13.9% and 7.5%, 10.5%, respectively. Analysis of variance showed that mean SBP significantly increased according to age (p < 0.0001) and BMI group (p = 0.001). Analysis of variance also showed that mean DBP significantly increased as age increased (p < 0.0001), but no significant difference was found between boys and girls in different age and BMI groups (p = 0.37). Our survey identified a high prevalence of overweight that was associated with elevated SBP among preschool-aged children in Iran. The effect of higher BMI on mean SBP is present in childhood and can be used as a predictor of high SBP even in children as young as 1-6 years.

The outcome of Iranian children on continuous ambulatory peritoneal dialysis: the first report of Iranian National Registry

BACKGROUND

Continuous ambulatory peritoneal dialysis is not a very common modality to treat Iranian children with end-stage renal disease; however, there is sometimes no choice but to offer this therapy to salvage the patient. Obviously, promotion in each program needs re-evaluation to find the pitfalls. Therefore, a nation-wide survey on pediatric continuous ambulatory peritoneal dialysis was conducted to find the cause of death or termination of dialysis.

METHODS

All children, younger than 14 years old, treated by continuous ambulatory peritoneal dialysis in nine main pediatric nephrology wards in Iran between 1993 and 2006 were included in this historical cohort study. Patient and technique survival rates were determined. Kaplan-Mayer and Cox-regression analysis were used to compare the survival. 2 x 2 table was used to calculate the risk ratio. A P<0.05 was considered significant.

RESULTS

One hundred twenty children with a mean age of 47.6 months were on continuous ambulatory peritoneal dialysis. The most frequent cause of renal failure was hereditary-metabolic-cystic disease. One hundred eighty-two peritoneal dialysis catheters were inserted surgically. The median first catheter exchange was 0.74 year (95%CI: 0.5 - 0.98). The most frequent cause of catheter replacement was catheter outflow failure due to displacement, adhesion, and infection (persistent peritonitis or tunnel infection). The mean patient survival was 1.22 years (95%CI: 0.91 - 1.53). The mortality rate was 55% before 1997, and 60% between 1998 and 2001, which declined to 23% after 2002 (P<0.05). Young age (<24 months) was the only independent factor that predicted mortality (P<0.05). The outcome of children was as follows: recovery of renal function (6.7%), renal transplantation (8.3%), switch to hemodialysis (16.7%), still on continuous ambulatory peritoneal dialysis (23.3%), death (43.3%), and lost to follow-up (1.7%).

CONCLUSION

The mortality is still high among Iranian children on peritoneal dialysis. Young age is the most important factor influencing on survival and mortality.

Fungal peritonitis in Iranian children on continuous ambulatory peritoneal dialysis: a national experience

INTRODUCTION

Fungal peritonitis (FP), causing catheter obstruction, dialysis failure, and peritoneal dysfunction, is a rare but serious complication of peritoneal dialysis. In this study, the frequency and risk factors of FP are evaluated in children who underwent peritoneal dialysis.

MATERIALS AND METHODS

A retrospective multicenter study was performed at the 5 pediatric peritoneal dialysis centers in Iran from 1971 to 2006, and FP episodes among 93 children were reviewed. Risk ratios were calculated for the clinical and demographic variables to determine the risk factors of FP.

RESULTS

Ninety-three children aged 39 months on average were included in study. Sixteen out of 155 episodes of peritonitis were fungi infections, all by Candida albicans. The risk of FP was higher in those with relapsing bacterial peritonitis (P = .009). Also, all of the patients had received antibiotics within the 1 month prior to the development of FP. Catheters were removed in all patients after 1 to 7 days of developing FP. Six out of 12 patients had catheter obstruction and peritoneal loss after the treatment and 5 died due to infection.

CONCLUSIONS

Fungal peritonitis, accompanied by high morbidity and mortality in children should be reduced by prevention of bacterial peritonitis. Early removal of catheter after recognition of FP should be considered.

Serum zinc and copper levels in children with chronic renal failure

We evaluated changes in serum zinc (Zn) and copper (Cu) levels in two groups of children with chronic renal failure (CRF)--children with CRF who were on regular hemodialysis (Group 1, n=40) and children with CRF who were on conservative management (Group 2, n=31)--and in one group of healthy children (Group 3, n=30). All of the participants in the study were between 5-18 years old, and the composition of the three groups was almost identical with respect to age and sex. The length of time the children in Group 1 had been on hemodialysis varied between 3 and 52 months (mean: 20.97+/-14.8 months). To evaluate the impact of the duration of dialysis on serum levels of Zn, we further sub-divided Group 1 patients into two subgroups: Subgroup A patients (n=20) had been on hemodialysis therapy for less than 18 months (mean: 8.85+/-4.83 months); Subgroup B patients (n=20) had been on hemodialysis therapy for longer than 18 months (mean: 33.1+/-10.86 months). The PIXE (proton-induced X-ray emission) was used for measuring the trace elements.

RESULTS

The mean serum level of Zn was lower in the Group 1 (hemodialysis group) children than in the children of Group 2 (on conservative management) and group 3 (healthy children) (p<0.001), but the difference was not significant between Groups 2 and 3. No significant differences in serum levels of Cu were found among the three groups. The serum level of Zn was lower in Subgroup B than in Subgroup A (p<0.001). The correlation test showed that there was an inverse linear relation between the length of time the child was on the hemodialysis regimen and serum Zn levels.

CONCLUSION

Chronic hemodialysis may lead to abnormalities in the serum levels of some trace elements in children with CRF that increase in severity with increasing duration of hemodialysis. Deficiencies of these trace elements--zinc in particular--may contribute to various conditions and symptoms in children undergoing chronic hemodialysis.

Evaluation of acute pyelonephritis with DMSA scans in children presenting after the age of 5 years

It is generally believed that infants are more susceptible to development of renal scarring after pyelonephritis than children over 5 years old. This view has led to differences in investigations and treatment according to age. The aim of this prospective study was to assess the occurrence of renal parenchymal lesion in children over 5 years admitted with a first-time symptomatic urinary tract infection (UTI). Between October 2000 and April 2002, 52 children aged over 5 years who were admitted to our department with probable acute pyelonephritis (APN) and a positive urine culture were included in this study. All children received antibiotics for 14 days. During the acute phase of infection, scintigraphy with technetium-99m-labeled dimercaptosuccinic acid (DMSA) and ultrasonography (US) were done. Voiding cystourethrography (VCUG) was performed in all children early in the course of the illness, generally within 5-7 days of hospitalization. When scintigraphy showed renal parenchymal changes, repeat scintigraphy was done after at least 3 months to assess the progression of renal abnormalities. Of the 52 children with a first-time documented pyelonephritis, cortical scintigraphy showed renal lesion in 41 children (78.8%). US was normal in all children with normal renal scintigraphy, while it detected renal abnormalities in 16 of the 41 (39 %) with abnormal scintigraphy (p <0.0001). Topographic analysis of the 165 focal lesions showed that 42.4% were localized to the upper poles, 17.5% to the middle third, and 40% to the lower poles of the kidneys. Repeat scintigraphy showed persistent lesions corresponding to those on the initial scan in nine (28.2%) of the 32 children. Renal lesions had partly regressed in 23 (71.8%) of the patients who underwent repeat scintigraphy. Vesicoureteral reflux was observed in 13.4% of kidneys and renal parenchymal abnormalities were identified in 71.4% and 72.2% of renal units, respectively, with and without reflux ( p >0.05). In conclusion, our data did not confirm the conventional opinion that the risk of renal scarring after pyelonephritis is low in children over the age of 5 years. Our findings suggest that renal scintigraphy may be a more appropriate method of investigation than VCUG for evaluation of the children over 5 years with acute pyelonephritis. Additionally, the frequency of scintigraphic changes is high, and a strategy based exclusively on ultrasound findings would miss about 61% of the abnormal renal units. We recommend that all children, irrespective of age, will benefit from further investigations that might prevent or limit the development of scarring process and renal complications.

Screening for vesicoureteral reflux and renal scars in siblings of children with known reflux

The incidence of vesicoureteral reflux (VUR) in the general population is less than 1%, but it is high in families with reflux. The reported prevalence of VUR among siblings of index patients with reflux has ranged from 4.7% to 51%. Reflux carries an increased risk of pyelonephritis and long-term renal impairment. The purpose of this study was to identify the age-related incidence and severity of reflux, and the frequency of associated renal parenchymal damage in siblings of children with reflux in order to assess the use of screening at different ages. Between October 1994 and February 2003, 40 siblings of 34 index patients were screened with direct voiding cystography. 99( m ) technetium (Tc)-dimercaptosuccinic acid (DMSA) nuclear renal scans were performed in siblings with VUR to detect renal scarring. The cystograms were interpreted as showing the presence or absence of VUR and the DMSA scan as symmetrical or asymmetrical differential function, with or without renal scarring. Of 40 siblings, 17 had VUR, representing an incidence of 42.5%. The mean age at study entry of the 15 boys and 25 girls was 63 months (range 6 months to 12 years). The majority of siblings with abnormal DMSA scans were asymptomatic. Reflux was unilateral in 12 siblings and bilateral in 5. Of the 17 refluxing siblings (22 refluxing ureters), 7 (41.17%) had a history of symptomatic urinary tract infection (UTI). The frequency of VUR was nearly equal in siblings over 6 years and those younger than 6 years. Of the 17 siblings with VUR, 16 had DMSA scintigraphy. Of these, 5 were normal and 11 (68.75%) showed abnormalities (7 asymmetrical differential function and 4 parenchymal defect), which was bilateral in 7 and unilateral in 4. In conclusion, this study confirms a significant overall incidence of VUR and renal parenchymal damage in the siblings of patients with known reflux. The prevalence of reflux in older siblings is similar to that in younger siblings. Our review suggests that all siblings over 6 years should undergo a screening cystogram, even in the absence of urinary tract infection. DMSA scintigraphy of asymptomatic siblings appears to be beneficial in preventing renal injury.

Blood pressure nomograms for school children in Iran

Currently there are no blood pressure (BP) nomograms based on local data available in Iran. In order to obtain data on BP distribution in Iranian school children, 8848 children aged 7-12 years were studied in Tehran. BP was found to increase with age. Both systolic and diastolic BP showed a positive correlation with height and weight in both sexes. The systolic and diastolic BP in boys and girls were not significantly different. As the sample was representative of Iranian school children, reference standard curves were constructed by modeling data using fractional polynomial. The 50th and 95th percentiles of systolic and diastolic BP of Iranian children were compared for each age with the results reported in the study of the Second Task Force. These percentiles were different from the Second Task Force study. Environmental and genetic determinants are likely to be responsible for the differences. The differences show that the use of local BP nomograms is necessary for assessing the BP levels in Iranian children.