Blood pressure to height ratio for screening hypertension among Indonesian adolescents

Background Pediatric hypertension is an emerging health issue due to its increasing prevalence. Age-, gender-, and height-specific blood pressure percentiles have been widely used as a primary tool for detection of hypertension in the pediatric population. However, this method is too complicated to be used in general pediatric practice. The blood pressure to height ratio has been proposed as a practical tool to detect hypertension in children. Objective To evaluate the accuracy of blood pressure to height ratio to be used as a tool for screening high blood pressure in Indonesian adolescents. Methods This diagnostic test study using data from the 2013 Indonesia Basic Health Research  (Riset Kesehatan Dasar/RISKESDAS) report included 39,057 adolescents aged 15-18 years with complete data on age, gender, weight, height, and blood pressure. Blood pressure values were classified using the 2017 American Academy of Pediatrics (AAP) hypertension clinical guidelines. Blood pressure to height ratio was calculated as mmHg/cm body height. A receiver-operator characteristics (ROC) curve analysis was performed to assess the accuracy of systolic blood pressure to height ratio (SBPHR) and diastolic blood pressure to height ratio (DBPHR) for screening high blood pressure in adolescents. The optimal cut-off points, sensitivity, and specificity of SBPHR and DBPHR were calculated. Results The optimal cut-off points for defining elevated blood pressure in male adolescents aged 13-18 years were SBPHR 0.69 for male adolescents (sensitivity 96%, specificity 80%) and DBPHR 0.46 (sensitivity 97%, specificity 84%). In female adolescents, the optimal cut-offs were SBPHR 0.72 (sensitivity 97%, specificity 82%) and DBPHR 0.48 (sensitivity 98% and specificity 79%). Conclusion Blood pressure to height ratio is a practical method with high sensitivity and specificity for detecting elevated blood pressure in Indonesian adolescents aged 15 to 18 years.

Experience of the first 6 years of pediatric kidney transplantation in Indonesia: A multicenter retrospective study

BACKGROUND

Pediatric kidney transplantation was only introduced in Indonesia in 2013. We therefore aimed to assess the characteristics and outcomes of transplants performed from its inception to January 2019.

METHOD

The study had a dual-center retrospective design. We examined the records of kidney transplant recipients and then calculated patient and graft survival rates by Kaplan-Meier survival analysis with 95% confidence intervals (95% CI).

RESULTS

In total, 12 kidney transplantations were performed in eleven children during the study period; among these, ten were boys, and nine had renal failure caused by congenital anomaly of the kidney or urinary tract. All donors were living, and all recipients were on dialysis at the time of transplantation, when their median age was 14.5 years (range, 8-19 years). Three patients died of infection in the first year of follow-up and two lost their allograft by the time of their last follow-up (median, 13 months; range, 4-69 months). The 1-year patient survival rate was therefore 68.18% (95% CI, 29.72%-88.61%), which remained unchanged at 3 and 5 years. However, the non-death-censored graft survival rates at 1, 3, and 5 years were 68.18% (95% CI, 29.72%-88.61%), 51.14% (95% CI, 14.5%-79.46%), and 25.57% (95% CI, 1.38%-64.78%), respectively.

CONCLUSION

Patient and graft survival rates after pediatric kidney transplantation in Indonesia are lower than those reported in other countries. Closer patient follow-up and stricter adherence to guidelines could improve transplant outcomes, but we must seek to improve the balance between infection and rejection.

Five-year experience of continuous ambulatory peritoneal dialysis in children: a single center experience in a developing country

BACKGROUND The pediatric peritoneal dialysis (PD) program in Cipto Mangunkusumo Hospital, Indonesia was started in 2014. However, there has been no published data on the patients’ outcome. This study was aimed to report the characteristics and outcomes of a continuous ambulatory peritoneal dialysis (CAPD) program for children. METHODS This retrospective study was conducted in Cipto Mangunkusumo Hospital as a national referral hospital. Data were collected from medical records of patients aged ≤18 years with end-stage renal disease who underwent CAPD in 2014–2019. The baseline characteristics, PD-related infection rate, as well as patient and technique survivals were analyzed. RESULTS Out of 60 patients who underwent CAPD, 36 (60%) were boys on the age range of 4 months–18 years. The mean follow-up duration was 12 (95% confidence interval [CI] = 9.4–15.3) months. The number of PD related infections increased along with the growing number of patients on CAPD. The peritonitis rate was 0.42 episodes per year at risk, and the most common etiology was alpha-hemolytic Streptococcus (5/24, [20.8%]). The 1- and 3-year technique survival rates were 60.3% (95% CI = 44.5–72.9) and 43.9% (95% CI = 23.2–62.9). The 1- and 3-year patient survival rates were 69.6% (95% CI = 52.5–81.5) and 58% (95% CI = 31.2–77.5). CONCLUSIONS In this unit, CAPD could be performed in children as young as 4 months of age. The peritonitis rate was relatively low which was likely caused by skin-derived microorganisms. Both technique survival and patient survival were also relatively low.

Delayed Admission and Management of Pediatric Acute Kidney Injury and Multiple Organ Dysfunction Syndrome in Children with Multiple Wasp Stings: A Case Series

Multiple wasp stings may cause fatal complications, such as anaphylactic reactions, intravascular hemolysis, rhabdomyolysis, acute kidney injury (AKI), increased levels of liver enzymes, clotting abnormalities, or even death. AKI-related mortality due to multiple wasp stings may reach 25%, occurring within the early onset of disease; therefore, renal function should be continuously monitored within the first few days following the stings. Herein, we report 2 cases of AKI due to multiple stings of wasp (Vespa affinis). In both cases, delayed hospital admissions and gradual loss of kidney function along with hemolysis and anemia without rhabdomyolysis were observed. Diuresis was reduced on the 10th day following the stings in the first case, whereas it occurred on the 5th day in the second case. Both cases had biopsy results of acute tubular injury and acute interstitial nephritis. The first case improved with intermittent hemodialysis, whereas the second required continuous renal replacement therapy and plasma exchange because hemolysis was more severe, which was presumably caused by a greater number of stings and larger amount of toxins involved. Multiple organ dysfunction syndrome was also observed in the second case; hence, high-dose steroid therapy was administered to alleviate interstitial fibrosis. Both cases showed that although AKI occurring after multiple wasp stings usually have fatal consequences. Administering fluid treatment and steroid therapy and selecting accurate renal replacement therapy modalities during the few first days after the stings may result in favorable long-term outcomes.

Asymptomatic proteinuria in Indonesian adolescent students

Proteinuria is one of the common manifestations of kidney disease that has a serious impact on the progressive deterioration of kidney function. In developed countries, school screening for asymptomatic proteinuria is routinely performed, especially in adolescent students, to detect early stage of chronic kidney disease. This study aimed to find out the prevalence of asymptomatic persistent proteinuria in adolescent students. This was a multi-assessment study. Screening for proteinuria was conducted on five junior high schools across Jakarta, Indonesia, in April-June 2015. Healthy students aged 12-14 years whose parents provided informed consent were selected randomly. Urine collections were performed thrice. We used dipstick tests and protein-to-creatinine ratio to measure protein in the urine. From 536 students, 485 were eligible and recruited for this study. They were more female and well-nourished students. Hypertension constituted 12.9% of students. Proteinuria accounted for 7.42%. Transient, orthostatic, and persistent proteinuria were found in 5.77%, 1.03%, and 0.62% of students, respectively. The prevalence of asymptomatic persistent proteinuria among adolescent students in Jakarta is higher than that in other populations in Asia. Consequently, a routine screening to detect proteinuria should be considered in Indonesia to detect chronic kidney disease in children.

Kidney Disease Profiles Among Adolescents In Indonesia

BACKGROUND

Each kidney injury may develop into chronic kidney disease (CKD) and end stage renal disease (ESRD) that associates with high mortality and socio-economic burden. There is limited data about clinical characteristics of children having CKD in developing countries, espesially in Indonesia.

OBJECTIVE

To describe clinical profiles and characteristics of kidney diseases in adolescents aged 15-18 years.

METHODS

This study was a cross-sectional study which used data from National Basic Health Survey (Riskesdas) 2013. There were 2 data groups. The first data group included questionnaires about history of kidney stone disease, hypertension, chronic renal failure, antihypertension administration, and blood pressure measurement. The second data group included subsamples of the first group which had laboratory test results, i.e. hemoglobin and serum creatinine levels. All of the data were classified by nutritional status, estimated glomerulofiltration rate (eGFR), blood pressure classification, and hemoglobin level.

RESULTS

Among 52,454 adolescents in the first data group, 20,537 (39%) had kidney diseases with female predominance and good nutritional status. Other findings found were history of kidney stone disease (0.2%), chronic renal failure (0.1%), history of hypertension (0.6%), antihypertensive agents consumption (0.1%). Prehypertension and hypertension were found in 51% and 48.3% of adolescents, respectively. Adolescents with decreased eGFR were accounted for 1.4%.

CONCLUSION

The proportion of prehypertension and hypertension in adolescents aged 15-18 years in Indonesia is high. Hence, routine blood pressure measurement is important for early detection and prevention of kidney disease progression.

Side effects of long-term antiepileptic drugs on renal tubules of Indonesian children

Background Long-term treatment with antiepileptic drugs such as valproic acid (VPA) and carbamazepine (CBZ) may disrupt renal tubular function. Urinary N-acetyl-beta-D-glucosaminidase (NAG) may reflect tubular function and may be useful in detecting early-stage tubular injury. To date, no study has investigated the toxic effect of VPA and CBZ on renal tubules using urinary NAG in Indonesian children. Objectives To determine the toxicity of long-term VPA and/or CBZ treatment on renal tubules in children with epilepsy by measuring urinary NAG index (iNAG). Methods This cross-sectional study was conducted from January to March 2015 at Cipto Mangunkusumo Hospital and Anakku Clinic Pondok Pinang, Jakarta. We included children aged 3 to 16 years with epilepsy on VPA (n=36), CBZ (n=14), or VPA-CBZ combination (n=14) therapy. We measured urinary levels of creatinine and NAG. The urinary NAG reference value was obtained from age-matched healthy controls (n=30). To eliminate diurnal variations in NAG, iNAG was calculated by dividing urinary NAG by urinary creatinine. A urinary iNAG of more than two standard deviations above the mean for healthy children was considered elevated. Results Mean urinary iNAG values for the control, VPA, CBZ, and combination groups were 3.01, 5.9, 4.07, and 6.9 U/g, respectively. All treated groups had higher mean urinary iNAG values compared to the control group. Urinary iNAG was increased in 11/36 children on VPA, 2/14 children on CBZ, and 9/14 children on combination therapy. Conclusion Long-term VPA use may impair renal tubular function, as shown by the increased urinary iNAG. Combination therapy increases damage in the renal tubules.

Telaah Kritis Makalah Uji Klinis

Evidence based medicine (EBM) ialah suatu carapendekatan untuk memanfaatkan buktimutakhir yang sahih dalam tatalaksana pasien.Untuk dapat memanfaatkan bukti mutakhirdiperlukan kemampuan untuk melakukan telaah kritisterhadap makalah atau hasil penelitian orang lainsebelum kita mengadopsi hasil penelitian tersebut. Carapendekatan EBM mengajarkan pokok-pokok untukmelakukan telaah kritis terhadap sebuah makalahdengan 3 patokan yang disingkat sebagai VIA, yaitu:"Validity" atau kesahihan penelitian, "Important" yangberarti pentingnya hasil penelitian, serta "Applicability"penerapan (aplikasi) hasil penelitian tersebut padalingkungan kita

Nefritis Tubulointerstisialis pada Kasus Anak yang Menjalani Biopsi Ginjal

Latar belakang. Nefritis tubulointerstisialis (NTI) adalah sindrom yang merupakan spektrum penyakit akutdan kronik, yang secara histologis ditandai oleh inflamasi dan kerusakan struktur tubulus dan interstisial,dengan sedikit pengaruh pada elemen glomerular dan vaskular. Diagnosis pasti ditegakkan berdasarkanbiopsi ginjal, karena tidak ada pemeriksaan klinis dan penunjang non invasif yang spesifik dan sensitif.Tujuan. Mengetahui gambaran histopatologi yang menunjukkan keterlibatan tubulointerstisialis sertahubungannya dengan gambaran klinis dan laboratorium pada kasus anak usia kurang dari 18 tahun yangmenjalani biopsi ginjal pada periode 2005-2009.Metode. Penelitian retrospektif deskriptif dengan sumber data sekunder rekam medik Departemen IlmuKesehatan Anak dan Departemen Patologi Anatomi Fakultas Kedokteran Universitas Indonesia – RS Dr.Cipto Mangunkusumo Jakarta.Hasil. Terdapat 45 kasus anak yang menjalani biopsi ginjal, terdiri dari 24 orang laki-laki dan 21 perempuanyang berusia 6 bulan sampai 16 tahun. Indikasi biopsi adalah glomerulonefritis akut, sindrom nefrotik,nefritis lupus, dan tumor ginjal. Gambaran klinis yang ditemukan yaitu edema, hipertensi, oliguria, demam,pucat, dan muntah. Gambaran laboratorium yaitu peningkatan kreatinin, asidosis metabolik, hipokalemia,proteinuria, hematuria, dan leukosituria steril. Gambaran nefritis tubulointerstisialis adalah infiltrasi selradang kronik, atrofi tubulus, fibrosis interstisialis, dan edema interstisialis. Beberapa gejala yang lebihbanyak terjadi pada pasien dengan lebih atau sama dengan satu kelainan tubulointerstisialis yaitu demam(p<0,05), anemia, muntah, dan asidosis metabolik.Kesimpulan. Nefritis tubulointerstisialis sebagai suatu entitas diagnosis cukup banyak ditemukan dan perludiberikan lebih banyak perhatian, dalam upaya menurunkan morbiditas dan mortalitas dari penyakit ginjalpada anak. 

Peran Transforming Growth Factor-B1 pada Penyakit Ginjal

Peran sitokin dan faktor pertumbuhan(growth factor)sangat penting dalam proses inflamasi yang mendasari pembentukan jaringan sklerotik dan fibrosis pada glomerulonefritis. Transforming growth factor(TGF)-E1merupakan sitokin multipoten yang disekresi oleh berbagai sel dalam tubuh. Sitokin TGF- E1 mempunyai kapasitas untuk mengaktivasi fibroblas interstisial, menginduksi apoptosis (yang menyebabkan sel intrinsik ginjal hilang, digantikan dengan jaringan fibrotik), dan diferensiasi sel tubulus menjadi miofibroblas, sehingga terjadi pembentukan jaringan parut ginjal. Jumlah (TGF)-E1 di daerah tubulo-interstisial berkorelasi dengan derajat inflamasi interstisial dan atrofi tubulus. Keterlibatan TGF-E1 pada pembentukan jaringan parut ginjal juga melalui peningkatan sintesis matriks ekstra selular. Diketahui bahwa TGF-E1 berperan dalam progresivitas penyakit ginjal. Kadar TGF-E1 di dalam urin kasus glomerulonefritis dengan proteinuria berat, sangat meningkat, dan kadarnya sebanding dengan derajat proteinuria. Peran TGF-E1 dalam progresivitas penyakit ginjal juga melalui terjadinya hipertensi. Angiotensin II sebagai hasil aktivasi sistim renin-angiotensin menstimulasi produksi TGF-E1. Inhibitor enzim konvertase (ACEI) dan atau antagonis reseptor angiotensin II terbukti dapat menurunkan proteinuria dan produksi TGF-E1, sehingga kedua obat tersebut dikenal mempunyai efek reno-proteksi.

The use of topical zinc in tuberculin test

with under-diagnosis or over-diagnosis commonly occurring. The tuberculin test as a supporting examination for tuberculosis infection has a false negative value rate of 10-25%. Also, a majority of children with tuberculosis have lower plasma zinc levels than healthy children. Zinc deficiency may impair the immune response, leading to more false negative skin-test results.Objective To evaluate the effectiveness of topical zinc for augmenting the diameter of tuberculin induration in children with tuberculosis.Methods This unblinded, clinical trial was performed from October to December 2012 in subjects matched with themselves. Subjects were children with tuberculosis aged 2-18 years at the Department of Child Health at Cipto Mangunkusumo Hospital and Persahabatan Hospital. Every subject was injected tuberculin in volar region of left and right arm. Test sites then were covered with topical zinc cream on the right arm and placebo cream on the left arm. Indurations were measured after 72 hours. The difference of tuberculin diameter of 3 mm was considered as clinically significant. Data analysis was performed with Wilcoxon signed rank test.Results There were 47 subjects in this study. The majority of subjects were well-nourished (53%). Subjects’ median treatment duration was < 6 months, median age was 72 months and 47% of subjects were under the age of five years. Sixteen subjects had a median 1 mm difference in tuberculin induration diameter between the zinc arm and placebo arm (P<0.001), but this was clinically insignificant. Twenty-two subjects (43%) had Koch reaction after zinc cream application, but the placebo cream did not cause Koch reaction.Conclusion Application of topical zinc does not increase tuberculin induration compared to placebo.

Urinalysis as a diagnostic tool for febrile urinary tract infection in children aged 2 months - 2 years

Background Children aged 2 months to 2 years with febrileurinary tract infection (UTI) need special attention consideringkidney complications, unspecified symptoms, and difficult urinesample collection. Urinalysis was the main supportive examinationfor UTI because of its immediate result and widespreadavailability.Objective To estimate urine nitrite, leukocyte esterase (LE),leucocyturia, bacteriuria, and their combinations as a diagnostictool for febrile UTI in children aged 2 months to 2 years.Methods This is a diagnostic study held in Cipto MangunkusumoHospital, Tangerang General Hospital, Fatmawati Hospital, andBudhi Asih Hospital, involving 7 5 children aged 2 months to 2years. Urine samples for urinalysis and urine culture were collectedusing urine collector in all subjects. Clinical pathologists whoperformed urine culture, did not know the results of urinalysis.Results By parallel test analyses, we found that the best diagnosticvalue was the combination of 3 tests (LE, leucocyturia, andbacteriuria). This combination test showed sensitivity, specificity,positive predictive value (PPV), negative predictive value (NPV),positive likelihood ratio (LR+), and negative likelihood ratio(LR-) of 69%, 95%, 85%, 88%, 13.1, and 0.3.Conclusion The combination test of LE, leucocyturia, andbacteriuria shows high specificity, NPV, and LR+ . Therefore, thenegative results of these 3 tests in combination can be used to ruleout UTI.

Acute kidney injury in asphyxiated neonates

Background Asphyxia neonatorum may result in multiorgandysfunction including renal involvement. There is no consensuson the determination of acute kidney injury (AKI) in neonatesmaking establishment of the diagnosis and its managementbecomes difficult. The Acute Kidney Injury Network (AKIN)recommends AKI criteria based on increased serum creatininelevel and reduced urine output.Objectives To identify the prevalence of AKI in asphyxiatedneonates using the AKIN criteria, to compare the difference ofAKI stages, and the glomerular filtration rates (GFR) betweenmoderate and severe asphyxia.Methods This was a cross-sectional analytical study conductedbetween July 2012 and January 2013. Subjects were all asphyxiatedneonates (Apgar score < 7 at fifth minute) with gestational age of>35 weeks delivered and hospitalized in Cipto MangunkusumoHospital and Koja District Hospital, Jakarta, Indonesia.Glomerular filtration rate was calculated using the componentsof urine creatinine, serum creatinine, and urine output; whileAKI stages were determined according to AKIN criteria. Urinaryoutput was measured via urethral catheterization.Results Of 94 subjects, there were 70 neonates with moderateand 24 neonates with severe asphyxia, with the prevalence of AKIwas 63%. Twenty one out of 24 neonates with severe asphyxiaexperienced AKI, while neonates with moderate asphyxia whoexperienced AKI was 38 out of 70 subjects (54%). Two third ofneonates with severe asphyxia who experienced AKI had stage3 of AKI. More severe AKI stages and lower median GFR werefound in neonates with severe compared to moderate asphyxia(P<0.001) .Conclusion The prevalence of AKI in neonatal asphyxia is high(63%). The more severe degree of neonatal asphyxia, the moresevere AKI stage and the lower median GFR.

Prognostic factors and survivals of children with steroid-resistant nephrotic syndrome

Background Children with steroid resistant nephrotic syndrome(SRNS) generally survive, although during the course of diseasetheir kidney function may decrease, leading to end-stage renaldisease (ESRD). There have been few studies reporting on thesurvivals of children with SRNS.Objectives To determine patient and kidney survival rates in childrenwith SRNS at the first, second, third, fourth, and fifth years; and toevaluate the effects of age at onset, initial kidney function, hypertension,and type of resistance, on the survivals of children with SRNS.Methods This retrospective cohort study was performed usingsecondary data obtained from medical records of patients with SRNS inDepartment of Child Health, Cipto Mangunkusumo Hospira~ between2004-2011. The outcomes of kidney survivals were defined in two ways:lack of doubling of base creatinine levels and lack of ESRD.Results There were 45 children with SRNS in our study. Their medianduration ofillness was 24 (range 12-95) months. Twenty percent of thesubjects died, 31.1 % had a doublingofbase creatinine levels, and 13.4%developed ESRD. Life survival rates of subjects at the first, second,third, fourth, and fifth years after diagnosis were 93 %, 84%, 80"/ri, 7 2%,and 61 %, respectively. Kidney survival rates determined by the lackof doubling of base creatinine levels at the first, second, third, fourthand fifth years were 92%, 72%, 56%, 42%, and 34%, respectively, whilekidney survival rates determined by the lack ofESRD were 97%, 88%,81 %, 70"/o, and 58%, respectively. Age at onset, initial kidney function,hypertension at onset, and type of resistance, did not significantly affectthe survivals of children with SRNS.Conclusion Children with SRNS are prone to develop a doublingof base creatinine levels and ESRD. Factors such as age, initialkidney function, hypertension at onset, and type ofresistance, donot significantly affect both, life and kidney survivals of childrenwith SRNS.

Procalcitonin levels in children aged 3-36 months with suspected serious bacterial infection

Background Fever in children aged 3-36 months is usually caused by viral infection, however, 11-20% of cases may progress into serious bacterial infection (SBI). A good diagnostic tool is required to detect SBI to reduce mortality and avoid unnecessary use of antibiotics.Objectives To determine procaldtonin (peT) levels, and etiology of bacteremia in febrile children aged 3-36 months old with suspected SBI.Methods A cross-sectional descriptive study was conducted in Cipto Mangunkusumo and Tangerang General Hospital during April-May 2010. Complete blood cells count and acute illness observation score (AIOS) were perfonned on febrile children aged 3-36 months. Subjects meeting the inclusion criteria underwent blood culturing and testing of procalcitonin levels.Results There were 39 children met the criteria. Boys and girls ratio was 1.6 Mth median age of 10 months. Mean of AlOS was 20.5 (4.5 SD) and mean of hemoglobin was 10.2 (SD 2.1) g/dL. Median of leukocyte and absolute neutrophyl count were 18,600/uL and 12,300/uL, respectively. Median of procaldtonin 1.8 (range 0.04-71.60) ng/mL, mean of procalc itonin in bacteremia subgroup 22.60 (SD 27.6) ng/mL and 6.38 in non-bacteremia subgroup (11.0 SB) ng/mL. In children with severely ill appearance, the likelihood of procaldtonin levels ≥2 ng/mL was 8.67 times higher (95%CI 1.66 to 50.56) than in moderately or mildly ill-appearing children. In subjects Mth procalcitonin level of ≥2 ng/mL, the risk of bacteremia was 8.1 times (95% CI 2.9 to 1051.6) higher and the risk of sepsis was 55.47 times higher than in subjects Mth procalcitonin <2 ng/mL (95% CI 1.22 to 68.02). We observed bacteriemia in 11 of 39 subjects (28.2%). The pathogens isolated from these 11 subjects were Klebsiella pneumonia, Staphylococcus aureus, Eschericia coli, Serratia marcesens, Staphylococrus saprophyticus, and Serratia liqueafaciens.Conclusion The proportion of bacteremia in children aged 3-36 months old with suspected serious bacterial infection was 28.2% with no predominant microorganism. Elevated procaldtonin level of ≥ 2 ng/mL was assodated with severe illness apppearance, bacteremia, and sepsis.