Immunological mechanisms of arterial damage in pediatric patients with primary hypertension

Primary hypertension is a disease that is being diagnosed with increasing frequency in pediatric patients, and many of them are found to have hypertension-mediated organ damage (HMOD), including arterial damage. The pathophysiology of primary hypertension and the formation of HMOD is multifactorial. One mechanism studied in recent years is the subclinical inflammation accompanying the elevation of blood pressure. Experimental studies, studies in adults and children, revealed the involvement of immune mechanisms in the formation of vascular lesions in the course of primary hypertension. The paper summarizes the current knowledge on this subject and points to possible therapeutic targets. Particular emphasis is placed on data from pediatric patients with primary hypertension, as a relation between arterial damage (early vascular aging) and immune system activation had already been found in children. The correct identification of immunological mechanisms may not only broaden our understanding of primary hypertension as a disease but also, more importantly, lead to the most effective methods of its treatment.

Nephrological and urological symptoms in patients with Robinow syndrome - a report of two cases

Robinow syndrome is a rare congenital syndrome described in 1969 by Meinhard Robinow. The genetic background is heterogeneous - mutations of DVLI1, DVLI3, WNT5A genes (mild, autosomal dominant inheritance) or ROR2 gene (severe, autosomal recessive inheritance) are responsible for the syndrome. The syndrome is characterized by facial dysmorphism, skeletal defects, short stature, cardiovascular and urinary system abnormalities.

CASE REPORT

We report nephrological and urological problems in two 4-year-old male patients with Robinow syndrome. The first patient has a horseshoe kidney located mainly on the right side, right vesicoureteral reflux grade II, dysfunctional voiding, buried penis, and retractile testicles. The second patient has recurrent urinary tract infections; diagnostic findings include left kidney duplication, grade II left vesicoureteral reflux, large posterior urethral diverticulum, dysfunctional voiding, buried penis, glanular hypospadias, and bilateral cryptorchidism.

CONCLUSIONS

Patients with Robinow syndrome require multidisciplinary care, including nephrology-urology care. Nephrological and urological manifestations in children with Robinow syndrome are diverse, and urinary tract defects may be atypical and complex.

Circadian Blood Pressure Profile in Pediatric Patients with Primary Hypertension

Our study aimed to evaluate factors affecting circadian BP profile and its association with hypertension-mediated organ damage (HMOD) in pediatric patients with primary hypertension (PH). The study included 112 children (14.7 ± 2.1 age, 79 boys, 33 girls) with untreated PH. Non-dipping was defined as a nocturnal drop in systolic or diastolic BP (SBP, DBP) < 10%, and a nocturnal drop >20% was defined as extreme dipping. The nocturnal SBP drop was 10.9 ± 5.9 (%), and the DBP drop was 16.2 ± 8.5 (%). Non-dipping was found in 50 (44.6%) children and extreme dipping in 29 (25.9%) patients. The nocturnal SBP decrease correlated with BMI Z-score (r = −0.242, p = 0.010) and left ventricular mass index (LVMI) (r = −0.395, p = 0.006); diastolic DBP decrease correlated with augmentation index (AIx75HR) (r = 0.367, p = 0.003). Patients with a disturbed blood pressure profile had the highest LVMI (p = 0.049), while extreme dippers had the highest augmentation index (AIx75HR) (p = 0.027). Elevated systolic and diastolic BP dipping were risk factors for positive AIx75HR (OR 1.122 95CI (1.009−1.249) and OR 1.095 95CI (1.017−1.177). We concluded that disturbed circadian BP profile was common in children with PH and should not be considered a marker of secondary hypertension. A disturbed circadian BP profile may be associated with higher body weight. In pediatric patients with PH, non-dipping is associated with increased left ventricular mass, and extreme dipping may be a risk factor for increased arterial stiffness.

Reduced Blood Pressure Dipping Is A Risk Factor for the Progression of Chronic Kidney Disease in Children

Background: Elevated blood pressure and proteinuria are well-established risk factors for chronic kidney disease (CKD) progression in children. This study aimed to analyze risk factors for CKD progress, emphasizing detailed ambulatory blood pressure (ABPM) data. Methods: In 55 children with CKD II−V, observed for ≥1 year or until initiation of kidney replacement therapy, we analyzed ABPM, clinical, and biochemical parameters. Results: At the beginning, the glomerular filtration rate (eGFR) was 66 (interquartile range—IQR: 42.8−75.3) mL/min/1.73 m2, and the observation period was 27 (16−36) months. The mean eGFR decline was 2.9 ± 5.7 mL/min/1.73 m2/year. eGFR decline correlated (p < 0.05) with age (r = 0.30), initial proteinuria (r = 0.31), nighttime systolic and mean blood pressure (r = 0.27, r = 0.29), and systolic and diastolic blood pressure dipping (r = −0.37, r = −0.29). There was no relation between mean arterial pressure during 24 h (MAP 24 h Z-score) and eGFR decline and no difference in eGFR decline between those with MAP 24 h < and ≥50 th percentile. In multivariate analysis, systolic blood pressure dipping (beta = −0.43), presence of proteinuria (beta = −0.35), and age (beta = 0.25) were predictors of eGFR decline. Conclusions: Systolic blood pressure dipping may be a valuable indicator of CKD progression in children.

Monogenic hypertension

Monogenic hypertension (MH) is a rare form of arterial hypertension (AH) in which a single gene mutation is responsible for developing the disease. This article discusses the pathogenesis, genetics, phenotype, and treatment of monogenic forms of AH. According to Guyton's hypothesis, mutations responsible for MH development most often lead to increased renal sodium reabsorption, in a mineralocorticoid-dependent or -independent mechanism, resulting in fluid retention and increased blood pressure. MH most often appears in childhood or adolescence and is characterized by moderate to severe blood pressure elevation and resistance to standard treatment. The coexistence of water-electrolyte abnormalities, most commonly hypokalemia and metabolic alkalosis, is characteristic but not always present. Monogenic AH should also be considered in patients with precocious or delayed puberty, growth deficiency, brachydactyly, and severe symptoms or hypertension mediated-organ damage. Identifying patients with monogenic hypertension is of utmost importance to implement appropriate treatment and reduce the risk of cardiovascular complications.

Evaluation of Active Renin Concentration in A Cohort of Adolescents with Primary Hypertension

Our study aimed to assess active renin concentration in children with primary hypertension. Thus, we evaluated active renin concentration, clinical parameters, office and ambulatory blood pressure, and biochemical parameters in 51 untreated adolescents with primary hypertension (median: 14.4 [interquartile range—IQR: 13.8–16.8] years) and 45 healthy adolescents. Active renin concentration did not differ between patients with hypertension and healthy children (median: 28.5 [IQR: 21.9–45.2] vs. 24.9 [IQR: 16.8–34.3] [pg/mL], p = 0.055). In the whole group of 96 children, active renin concentration correlated positively with serum potassium and office and ambulatory systolic and diastolic blood pressures. Among children with hypertension, patients with isolated systolic hypertension had lower renin concentration than patients with systolic-diastolic hypertension (26.2 [IQR: 18.6–34.2] vs. 37.8 [IQR: 27.0–49.6] [pg/mL], p = 0.014). The active renin concentration did not differ between patients with isolated systolic hypertension and healthy children. In multivariate analysis, diastolic blood pressure Z-score (beta = 0.238, 95 confidence interval [0.018–0.458], p = 0.035) was the only predictor of active renin concentration in the studied children. We concluded that active renin concentration is positively associated with blood pressure and potassium in children, and diastolic blood pressure was the strongest predictor of renin level. Patients with isolated systolic hypertension may differ from patients with systolic-diastolic hypertension in less severe activation of the renin-angiotensin-aldosterone system.

MO1036: 24-H Central Blood Pressure is Related to Renal Lesions in Children with Tuberous Sclerosis Complex

BACKGROUND AND AIMS

Adult data show that in people with tuberous sclerosis complex (TSC), blood pressure is related to the extent of renal involvement. Central blood pressure and 24-h ambulatory blood pressure are stronger predictors of a cardiovascular burden compared to office peripheral blood pressure. The study aimed to analyse 24-h central blood pressure and its relation with renal involvement in paediatric patients with TSC.

METHOD

In a group of 32 children with TSC (9.6 ± 4.4 years, 16 boys, 16 girls), we evaluated peripheral and central 24-h ambulatory blood pressure, office peripheral blood pressure, medications used, renal lesions in magnetic resonance and ultrasonography, including the presence of angiomyolipoma (AML), atypical AML, cysts and their maximal diameter (mm) and laboratory parameters.

RESULTS

In the studied group, 20 (62.5%) children had renal angiomyolipomas, including 5 (15.6%) with atypical angiomyolipomas, 22 (68.8%) with renal cysts and 4 children (12.5%) were treated with mTOR inhibitors (2 patients with everolimus and 2 patients with sirolimus) at the moment of evaluation, glomerular filtration rate (GFR) was 127.4 ± 36.7, one patient had GFR 80.5, 22 patients had GFR between 90 and 139 and 9 patients had hyperfiltration defined as GFR &gt; 140 mL/min/1.73 m2. A total of 4 (12.5%) children had elevated blood pressure in ABPM. The 24-h central systolic and diastolic blood pressure correlated with maximal diameter of renal cysts (mm) (r = 0.359, P = .044; r = 0.466, P = .029) and urinary albumin loss (mg/24-h) (r = 0.511, P = .004; r = 0.478, P = .021), 24-h central systolic, mean blood pressure and pulse pressure with serum cystatin-C (ng/mL) (r = 0.523, P = .005; r = 0.464, P = .015; r = 0.419, P = .029); 24-h peripheral MAP Z-score correlated with cyst size (mm) (r = 0.571, P = .021). No significant correlations between presence and AML size and peripheral and central blood pressure were found in the study group. There were following positive correlations of arterial stiffness parameters: 24-h central augmentation index (24hcAI x 75HR) with total cholesterol (r = 0.357, P = .045) and ambulatory arterial stiffness index (AASI) with uric acid (r = 0.520, P = .003). Size of AML correlated with age (r = 0.468, P = .007), whereas there was no correlation between cyst size and age (r = 0.145, P = .416).

CONCLUSION

MO1025: Periostin as a Potential Biomarker of Renal and Arterial Damage in Children with Tuberous Sclerosis Complex

BACKGROUND AND AIMS

Experimental data suggest that periostin is involved in the formation of renal cysts. Tuberous sclerosis complex (TSC) is a multisystem genetic disease characterized by the formation of lesions in virtually all organs, including the kidney—most commonly angiomyolipomas (AML) and cysts. There are no reliable markers of progression of renal lesions in patients with TSC. The study aimed to evaluate serum periostin levels in children with TSC and to assess the usefulness of periostin as a marker of renal lesion severity and arterial damage in this group of patients.

METHOD

In a group of 35 children with TSC (mean age 8.46 ± 5.64 years, 17 boys, 18 girls), serum periostin levels (ng/mL), anthropometric parameters, renal changes (by ultrasound and magnetic resonance imaging), blood pressure and biochemical parameters were evaluated. The control group consisted of 25 healthy children (mean age 8.72 ± 4.73 years, 14 boys, 11 girls). In addition, central pressure and parameters of arterial structure and function (cIMT, PWV, AIx75HR) were assessed in 20 children with TSC and 17 healthy children (age ≥ 4 years).

RESULTS

Arterial hypertension was found in two (5.7%) patients; AML was present in 20 (57.1%) children, including 9 (27.3%) atypical AML and 22 (62.8%) had cysts in the kidneys. Children with TSC did not differ in periostin levels compared with healthy children [67.46 ± 35.61 versus 68.14 ± 24.07 (ng/mL), P = .499]. In children with TSC, periostin concentration was negatively correlated with age (r = −0.614, P &lt; .001), height (r = −0.634, P &lt; .001), body weight (r = −0.658, P &lt; .001), maximum cyst size (r = −0.481, P = .004) and office and ABPM systolic and diastolic blood pressure (r = −0.396 to −0.621, P &lt; .050). There was no relationship between periostin levels and AML size or arterial damage parameters. In multivariate analysis, the only determinant of serum periostin levels in children with TSC was age [beta = −0.547, 95% confidence interval (95% CI) (−0.831 to −0.262)].

CONCLUSION

The usefulness of serum periostin determination as a marker of renal cystic lesions in children with tuberous sclerosis requires further study.

MO1031: Burnout Syndrome Among Paediatric Nephrologists—Report on its Prevalence, Severity and Predisposing Factors

BACKGROUND AND AIMS

Burnout is an occupational-related syndrome comprising emotional exhaustion, depersonalization and reduced feelings of work-related personal accomplishments. Addressing and mitigating burnout is essential for avoiding high workforce turnover, patient dissatisfaction and a lower quality of care. There are some reports on burnout among adult nephrologists and general paediatricians, but little has been known about burnout among paediatric nephrologists. The aim of our study was to assess the prevalence and severity of burnout syndrome among Polish paediatric nephrologists.

METHOD

A 25-items online survey consisting of abbreviated Maslach Burnout Inventory and additional self-created questions about work-related factors was completed by 97 physicians affiliated with the Polish Society of Paediatric Nephrology. 75.3% of them were women, the median time of professional experience in the study group was 15 years.

RESULTS

High level of emotional exhaustion, depersonalization and reduced feeling of personal accomplishments was observed in 39.2%, 38.1% and 21.6% of participants, respectively. 26.8% of participants presented at least a medium level of burnout in all three dimensions and 8.2% of them presented high three-dimensional burnout. No associations of burnout intensity and gender, job seniority and the use of holiday leave were found. 41.2% of participants stated, that they would like to take part in burnout prevention and support programme. According to the study participants, excessive bureaucracy in healthcare systems, rush and working overtime were the main job-related problems that can influence burnout intensity.

CONCLUSION

Burnout is an important factor in the professional landscape of paediatric nephrology. Actions aiming at reducing the risk of occupational burnout among paediatric nephrologists should be applied both at personal and institutional levels.

Burnout Syndrome among Pediatric Nephrologists—Report on Its Prevalence, Severity, and Predisposing Factors

Background and Objectives: Burnout is an occupation-related syndrome comprising emotional exhaustion, depersonalization, and reduced feelings of work-related personal accomplishments. There are reports on burnout among adult nephrologists and general pediatricians, but little is known about burnout among pediatric nephrologists. The aim of our study was to assess the prevalence and severity of burnout syndrome among Polish pediatric nephrologists. Materials and Methods: A 25-item study survey consisting of abbreviated Maslach Burnout Inventory and additional self-created questions about work-related factors was completed by 97 physicians affiliated with the Polish Society of Pediatric Nephrology. Women comprised 75.3%, with median time of professional experience in the study group was 15 years. Results: A high level of emotional exhaustion, depersonalization, and reduced feeling of personal accomplishments were observed in 39.2%, 38.1%, and 21.6% of the participants, respectively. At least a medium level of burnout in all three dimensions were observed in 26.8% of the participants and 8.2% of them presented high three-dimensional burnout. About 41.2% of the participants stated that they would like to take part in burnout prevention and support programs. According to the study participants, excessive bureaucracy in healthcare systems, rush at work, and overtime work were the main job-related problems that could influence burnout intensity. Conclusions: Burnout is an important factor in the professional landscape of pediatric nephrology. Actions aimed at reducing the risk of occupational burnout among pediatric nephrologists should be applied, both at the personal and institutional levels.

[Hypertensive urgencies and emergencies in pediatric patients]

Hypertensive crisis is a sudden rise in blood pressure that is significantly above normal values. Depending on the severity of symptoms, hypertensive crisis can be classified as hypertensive urgency, i.e. severe arterial hypertension (AH) without organ failure and damage with nonspecific symptoms (pain, dizziness, nosebleeds, nausea, vomiting), and hypertensive emergency, i.e. severe AH with organ failure and/or acute organ damage. The most common causes of hypertensive crisis in neonates and infants are vascular diseases (thrombus or stenosis of the renal artery, coarctation of the aorta) or renal parenchymal diseases, in older children kidney diseases and renal artery stenosis, in adolescents also intoxications or pregnancy. In neonates and infants, nonspecific symptoms caused by acute heart failure predominate, and in older children, symptoms from the central nervous system are most typical. Fast- and short-acting medications are used in the treatment of hypertensive urgencies and emergencies; a gradual normalization of blood pressure within 36-48 hours is recommended. Hypertensive emergencies are treated with intravenous drugs (e.g., labetalol, hydralazine), and hypertensive urgencies with intravenous or oral drugs such as nifedipine, clonidine, and minoxidil. Hypertensive emergencies are treated with intravenous drugs (e.g., labetalol, hydralazine), and hypertensive urgencies with intravenous or oral drugs such as nifedipine, clonidine, and minoxidil. Emergency conditions are treated with intravenous drugs (e.g., labetalol, hydralazine), urgent conditions with intravenous or oral drugs such as nifedipine, clonidine, and minoxidil. Some causes of hypertensive crisis require different management, e.g. alpha-blockers in pheochromocytoma. In all patients, evaluation of target organ damage and extensive diagnostics for secondary forms of hypertension is necessary.

Serum Sclerostin Is Associated with Peripheral and Central Systolic Blood Pressure in Pediatric Patients with Primary Hypertension

Recent studies showed the significance of the canonical Wnt/beta-catenin pathway and its inhibitor—sclerostin, in the formation of arterial damage, cardiovascular morbidity, and mortality. The study aimed to assess serum sclerostin concentration and its relationship with blood pressure, arterial damage, and calcium-phosphate metabolism in children and adolescents with primary hypertension (PH). Serum sclerostin concentration (pmol/L) was evaluated in 60 pediatric patients with PH and 20 healthy children. In the study group, we also assessed calcium-phosphate metabolism, office peripheral and central blood pressure, 24 h ambulatory blood pressure, and parameters of arterial damage. Serum sclerostin did not differ significantly between patients with PH and the control group (36.6 ± 10.6 vs. 41.0 ± 11.9 (pmol/L), p = 0.119). In the whole study group, sclerostin concentration correlated positively with height Z-score, phosphate, and alkaline phosphatase, and negatively with age, peripheral systolic and mean blood pressure, and central systolic and mean blood pressure. In multivariate analysis, systolic blood pressure (SBP) and height expressed as Z-scores were the significant determinants of serum sclerostin in the studied children: height Z-score (β = 0.224, (95%CI, 0.017–0.430)), SBP Z-score (β = −0.216, (95%CI, −0.417 to −0.016)). In conclusion, our results suggest a significant association between sclerostin and blood pressure in the pediatric population.

Serum Periostin as a Potential Biomarker in Pediatric Patients with Primary Hypertension

Experimental studies suggest that periostin is involved in tissue repair and remodeling. The study aimed to evaluate serum periostin concentration as potential biomarker in pediatric patients with primary hypertension (PH). We measured serum periostin, blood pressure, arterial damage, biochemical, and clinical data in 50 children with PH and 20 age-matched healthy controls. In univariate analysis, children with PH had significantly lower serum periostin compared to healthy peers (35.42 ± 10.43 vs. 42.16 ± 12.82 [ng/mL], p = 0.038). In the entire group of 70 children serum periostin concentration correlated negatively with peripheral, central, and ambulatory blood pressure, as well as with aortic pulse wave velocity (aPWV). In multivariate analysis, periostin level significantly correlated with age (β = -0.614, [95% confidence interval (CI), -0.831--0.398]), uric acid (β = 0.328, [95%CI, 0.124-0.533]), body mass index (BMI) Z-score (β = -0.293, [95%CI, -0.492--0.095]), high-density lipoprotein (HDL)-cholesterol (β = 0.235, [95%CI, 0.054-0.416]), and triglycerides (β = -0.198, [95%CI, -0.394--0.002]). Neither the presence of hypertension nor blood pressure and aPWV influenced periostin level. To conclude, the role of serum periostin as a biomarker of elevated blood pressure and arterial damage in pediatric patients with primary hypertension is yet to be unmasked. Age, body mass index, uric acid, and lipid concentrations are key factors influencing periostin level in pediatric patients.

[Uric acid in children and adolescents with primary hypertension]

Increased concentration of uric acid may play a role in the pathogenesis of primary hypertension (PH).

AIM

The aim of the study was to assess concentration of uric acid and to assess its correlation with selected clinical and biochemical parameters in children with PH.

MATERIALS AND METHODS

In a group of 57 untreated pharmacologically children with PH (44 boys, 13 girls, mean age 14.99±2.84 years) following parameters were assessed: serum uric acid concentration, blood pressure in office measurement and in 24-hour ambulatory blood pressure monitoring (ABPM), and selected clinical and biochemical parameters. Control group consisted of 20 healthy children (mean 14.11±2.99 years).

RESULTS

Serum uric acid concentration was significantly higher in children with PH compared to healthy children (5.72±1.38 vs. 4.55±1.07 mg/dL; p=0.001). In patients with PH, its concentration was significantly higher in boys compared to girls ((6.12±1.20 mg/dL vs. 4.35±1.13 mg/dL, p<0.001), no such difference was found in healthy children. In the PH group, uric acid concentration correlated positively with age (r=0.426, p=0.001), height (r=0.557, p<0.001), weight (r=0.518, p<0.001), weight Z- score (r=0.296, p=0.025), BMI (r=0.316, p=0.017), neutrophil count (r=0.280, p=0.035), systolic blood pressure (r=0.375, p=0.004) and pulse pressure (r=0.444, p=0.001) in ABPM and negatively with HDL cholesterol, heart rate (r=-0.310, p=0.02 (1=-0.309, p=0.020) and nighttime diastolic blood pressure dip (r=-0.268, p=0.044) in ABPM. In multivariate analysis, the determinants of uric acid concentration in children with PH were sex (Β = 0,367, 95%CI(0.122-0.611), p=0.004) and weight Z-score (Β= 0.254, 95%CI(0.005-0.504), p=0.046).

CONCLUSIONS

Children with PH have increased serum uric acid concentration compared to healthy children. The risk factors for hyperuricemia in pediatric patients with PH are male sex and high body weight.

Early Vascular Aging in Children With Tuberous Sclerosis Complex

Objectives: Experimental data indicate that activating mutations in the mTOR (mammalian target of rapamycin) pathway may lead to abnormal arterial wall structure. Vascular anomalies like arterial stenoses are reported in pediatric patients with tuberous sclerosis complex (TSC). In addition, large renal lesions (angiomyolipoma-AML and cysts) are risk factors for arterial hypertension in adult patients with TSC. This study aimed to assess blood pressure, including central blood pressure and arterial damage (early vascular aging-EVA) in children with TSC. Materials and Methods: In a group of 33 pediatric patients with TSC (11.13 ± 4.03 years, 15 boys, 18 girls), we evaluated peripheral and central office blood pressure, 24-h ambulatory blood pressure, and arterial damage: aortic pulse wave velocity (aPWV) [m/s], [Z-score], augmentation index (AIx75HR [%]), common carotid artery intima-media thickness (cIMT) [mm], [Z-score], stiffness of common carotid artery (E-tracking), renal lesions in magnetic resonance and ultrasonography, and selected biochemical parameters. The control group consisted of 33 healthy children (11.23 ± 3.28 years, 15 boys, 18 girls). Results: In TSC group 7 (21.2%) children had arterial hypertension, 27 (81.8%) children had renal angiomyolipomas, 26 (78.8%)-renal cysts, and 4 (12.1%) patients were treated with mTOR inhibitors (2 patients with everolimus and 2 patients with sirolimus) at the moment of evaluation. Children with TSC had higher central systolic blood pressure (AoSBP) (98.63 ± 9.65 vs. 90.45 ± 6.87 [mm Hg], p < 0.001), cIMT (0.42 ± 0.05 vs. 0.39 ± 0.03 [mm], p = 0.011), cIMT Z-score (0.81 ± 1.21 vs. 0.16 ± 0.57, p = 0.007), aPWV (4.78 ± 0.81 vs. 4.25 ± 0.56 [m/s], p = 0.003) and aPWV Z-score (-0.14 ± 1.15 vs. -0.96 ± 0.87, p = 0.002) compared to healthy children, without differences in AIx75HR (8.71 ± 15.90 vs. 5.24 ± 11.12 [%], p = 0.319) and stiffness of common carotid artery. In children with TSC AoSBP correlated positively with serum cystatin C concentration (r = 0.377, p = 0.030) and with maximum diameter of renal cyst (R = 0.419, p = 0.033); mean arterial pressure (MAP) 24 h Z-score correlated with serum cystatin C concentration (R = 0.433, p = 0.013); and aPWV Z-score with daily urinary albumin loss [mg/24 h] (R = 0.412, p = 0.029). Conclusions: Children with tuberous sclerosis complex are at risk of elevated central blood pressure and early vascular aging. In children with TSC, blood pressure and arterial stiffness are related to renal involvement.

[Hypertensive crisis in a 3-year-old boy - neurovascular conflict?]

Hypertensive crisis is a sudden rise in blood pressure with accompanying clinical symptoms. The disease is extremely rare in small children and is always a complication of secondary hypertension.

CASE REPORT

3-year-old boy (spontaneous delivery, 37 week of gestation, birth weight 2170g, 10 AS, unremarkable family history) was admitted to a hospital because of weight loss (1.5 kg, i.e. approx. 15% in 6 months), anorexia, abdominal and limb pain and lethargy. On admission, very high blood pressure values (190/150 mm Hg), lean subcutaneous tissue, frequent blinking, height 88 cm (<3c), body weight 9.5 kg (<3c). In additional tests: blood morphology, parameters of renal function, ions, gasometry, catecholamine urinary excretion, steroid profile and daily cortisol profile were within normal limits. Elevated plasma renin activity was found. In imaging studies kidneys, adrenal glands and renal arteries were normal. Normotension was not obtained on two antihypertensive drugs - metoprolol and amlodipine. In angio-CT tortuous right vertebral artery, extending to the left on the anterolateral surface of the medulla oblongata - possible compression of the vessel of the left side of medulla - was found. Diagnosis of neurovascular conflict was made. The patient was consulted by neurosurgeon who declare no possibility of surgical treatment of anomalies. In the treatment, according to the literature, a drug blocking the renin-angiotensin-aldosterone-enalapril system was used, which normalized blood pressure. At the same time, intensive nutritional treatment was used. Resolution of symptoms and weight gain was observed. In further follow-up patients' parents withdrew enalapril lawlessly, which did not lead to recurrent rise in blood pressure. The latter may suggest other, transient cause of hypertensive crisis e.g. intoxication.

CONCLUSIONS

Severe hypertension in pediatric patients can give symptoms as weight loss and behavioral disorders. In the diagnostic of hypertensive crisis in children, neuroimaging studies and toxicological tests should be performed.

[Cerebral salt wasting syndrome as a complication of subarachnoid hemorrhage in a girl with nephrotic syndrome - a case report]

INTRODUCTION

Cerebral salt wasting syndrome (CSWS), characterized by natriuresis, polyuria, and hypovolemia, is a rare complication of central nervous system injury or disease.

A CASE STUDY

12-year-old girl was admitted with second attack of nephrotic syndrome (NS). On admission she presents with edema, blood pressure 110/60 mm Hg, proteinuria 145 mg/kg/24h, hypoalbuminemia (1.7 g/dL), GFR 94.4 mL/min/1.73m2, sodium 133 mmol/L. On 5th day the patient developed thrombosis of right subclavian and axillary vein and was treated with recombinant tissue plasminogen activator (0.3 mg/kg/h i.v.). 45 minutes after onset of the infusion severe headache appeared. Computed tomography revealed subarachnoid hemorrhage in a region of left occipital lobe and posterior 1/3 part of sickle of the brain. Control ultrasonography examination revealed resolution of the thrombus. No deficits were found on neurologic examination. Proteinuria subsided on 11th day of hospitalization. After the hemorrhage hypovolemia, hypotension (80/40 - 100/60 mm Hg, heart rate 100/min), polyuria, and pathologic natriuresis (up to 13.0 mmol/kg/24h) were observed. Cerebral salt wasting syndrome was recognized. The girl was supplemented with oral and intravenous sodium (up to 10 mmol/ kg/24h). In following days gradual decrease of diuresis and urinary sodium loss was observed. The patient was discharged home after 41 days with normal diuresis (1.5l/24h) and natriuresis (1.44 mmol/kg/24h).

CONCLUSIONS

Treatment of thromboembolic complications in children with NS poses a risk of central nervous system bleeding. Serum sodium concentration and diuresis must be strictly monitored in patients with central nervous system lesion, especially in the course of nephrotic syndrome.

[Evaluation of renal lesions in children with tuberous sclerosis - summary of the first year of follow-up program]

Tuberous sclerosis complex (TSC) is a genetic disease that leads to formation of tumors i.e. in brain kidneys, heart, lungs, and skin.

AIM

The aim of the study was to summarize center's experience in the first year of program of nephrologic follow-up in patients with TSC.

MATERIALS AND METHODS

During 12 months 30 children with TSC (14 boys and 16 girls aged from 3 months to 17 years 11 months, mean 7.57±5.02 years) were hospitalized. Following parameters were evaluated: genetic and biochemical tests, blood pressure in ambulatory blood pressure monitoring (ABPM), kidney lesions in ultrasonography (30 patients) and in magnetic resonance (14 patients).

RESULTS

Genetic tests were performed in 6 children - in 5 TSC2 mutation was found, in one boy with TSC and numerous renal cysts only PKD1 mutation was revealed. Mean GFR was 130.81±23.23 mL/ min/1.73 m2. Four children (13.3%) had arterial hypertension. Renal lesions were found in 28 (93.3%) children: 18 patients had angiomyolipomas (AML) (mean diameter 15.4±12.5, max 38 mm), 23 patients had renal cysts (mean diameter 7.6±7.0, max 30 mm); 13 patients had AMLs and cysts. A dysplastic lesion (39x26x15 mm) in right kidney was found in one girl. Children with AML were older than remaining patients (10.08±4.55 vs. 4.25±3.50 [years], p<0.001). Children with cysts were characterized by higher systolic (p=0.017), diastolic (p=0.027) and mean (p=0.014) arterial pressure, and mean arterial pressure Z-score (p=0.025) in ABPM. Maximal kidney cyst diameter correlated positively with systolic, diastolic, mean arterial pressure, mean arterial pressure Z-score, and diastolic blood pressure load in ABPM (r = 0.61-0.75, p = 0.033-0.005). Two children with numerous AML with diameter >30 mm were treated with sirolimus.

CONCLUSIONS

Because of common focal lesions in kidneys children with TSC should be kept under regular nephrologic follow-up. Presence of large renal cysts may predispose children with TSC to arterial hypertension.

Renalase in children with chronic kidney disease

Background: Renalase is kidney-derived molecule initially considered as catecholamine-inactivating enzyme. However, recent studies suggest that renalase exerts potent cardio- and nephroprotective actions, not related to its enzymatic activity. Purpose: To assess renalase level in children with chronic kidney disease (CKD). Material and methods: Serum renalase, BMI, arterial stiffness, peripheral and central blood pressure, intima-media thickness (IMT), medications, and biochemical parameters were analyzed in 38 children with CKD (12.23 ± 4.19 years) (stage G2-5). Control group consisted of 38 healthy children. Results: In the study group, GFR was 25.74 ± 8.94 mL/min/1.73 m²; 6 children were dialyzed; 26 had arterial hypertension. Renalase level was higher in the study group compared to control group (p < 0.001). In CKD children renalase correlated (p < 0.05) with BMI Z-score (r = -0.36), alfacalcidol dose (r = 0.41), GFR (r = -0.69), hemoglobin (r = -0.48), total cholesterol (r = 0.35), LDL-cholesterol (r = 0.36), triglycerides (r = 0.52), phosphate (r = 0.35), calcium-phosphorus product (r = 0.35), parathormone (r = 0.58), and pulse wave velocity Z-score (r = 0.42). In multivariate analysis GFR (β = -0.63, p < 0.001), triglycerides (β = 0.59, p = 0.002), and alfacalcidol dose (β = -0.49, p = 0.010) were determinants of renalase. Conclusions: In children with CKD there is a strong correlation between renalase level and CKD stage. Furthermore, in these patients renalase does not correlate with blood pressure but may be a marker of arterial stiffness.

[Zwiększenie częstości zachorowania na ostre popaciorkowcowe kłębuszkowe zapalenie nerek w pierwszej połowie roku 2018 - doświadczenie jednego ośrodka]

Acute poststreptococcal glomerulonephritis (APSGN) is a complication of infection with group A beta-hemolytic streptococcus. The disease manifests as microscopic/gross hematuria, arterial hypertension, edema, and acute kidney injury and has most commonly self-limiting course.

AIM

The aim of study was the analysis of clinical course of APSGN in period of increased incidence in the first half of 2018.

MATERIALS AND METHODS

We analyzed following parameters in children hospitalized due to APSGN in January-June 2018: age, sex, anthropometric parameters, preceding infection, clinical signs, renal function, biochemical and immunological tests (including antristreptolysins (ASO) and complement), urinalysis, renal ultrasonography, and treatment. The incidence of APSGN in years 2007-2018 was analyzed.

RESULTS

We found 11 children (6 boys, 5 girls) aged 5.01±2.44 years. The disease was preceded by pharyngitis in 8, skin infection in 1 with latent period 16.40±5.77 days. Clinical symptoms were: gross hematuria in 8, edema in 6, hypertension in 5, renal function impairment 6, and hyperkalemia in 5; all patients had lowered C3 complement factor; ASO was elevated in all patients except for a boy with skin infection. During hospitalization clinical symptoms resolved in all children; significant elevation in GFR (p=0.018) and C3 (p=0.034), and decrease in proteinuria (p=0.039) were observed. Four patients with abnormal ultrasonographic kidney image were characterized by worse kidney function (p=0.018), higher potassium concentration (p=0.052), higher proteinuria (p=0.073) and erythrocyturia (p=0.015) than remaining children. In follow-up (after 142,00±89,20days) all children had normal renal function and blood pressure, 1 patient had proteinuria, and 4 had erythrocyturia.

CONCLUSIONS

In most cases APSGN is characterized by rapid resolution of symptoms and good prognosis, but patients require periodic follow-up visits. Abnormal initial ultrasonographic kidney image may be a marker of worse clinical course of APSGN.

[Accidentally diagnosed distal renal tubular acidosis with nephrocalcinosis - a case report]

Distal renal tubular acidosis is a defect of acidification of urine in distal tubule. Full-blown form is characterized by polyuria, growth deficiency, nephrolithiasis or nephrocalcinosis. Mutations in genes encoding Cl-/HCO3 - exchanger (autosomal dominant) or H+-ATPase (autosomal recessive) are the most frequent in children.

A CASE REPORT

In a boy aged 2,5 years, healthy, with proper development, metabolic acidosis with hyperchloremia, hypokalaemia, normal glomerular filtration rate and alkaline urine was discovered during hospitalization because of pneumonia. USG showed normal length kidney with nephrocalcinosis type IIB. The family history revealed nephrocalcinosis on the part of the boy's father. He also had metabolic acidosis in blood gas test. Genetic test in a boy and his father showed mutation of SLC4A1(17q21-q22) gene encoding Cl-/HCO3 - exchanger. The boy was treated with 8,4% NaHCO3 - orally (1mEq/kg/24h) and KCl (0,3 mEq/kg/24h). We obtained normalization of blood gas test and potassium concentration.

CONCLUSIONS

Every child, with accidentally discovered metabolic acidosis, even with normal development, should be diagnosed in case of renal tubular acidosis. Electrolytes, gas blood test, urinalysis and USG are needed in the closest family members of child with diagnosed renal tubular acidosis.

Twenty years of growth hormone treatment in dialyzed children in Poland-Results of national multicenter study

PURPOSE

The aim of the study was to analyze the effect of recombinant human growth hormone (rhGH) therapy and to establish factors influencing growth rate in dialyzed children in Poland.

METHODS

We retrospectively analyzed medical records of 81 children with end-stage renal disease (ESRD) on chronic dialysis treated with rhGH for ≥12 months between 1994 and 2014. The following data were recorded: cause of ESRD, dialysis modality, age at the dialysis and rhGH initiation [years]. In addition, growth [cm], [standard deviation score - SDS], body mass index [SDS], skeletal age [years], bone mineral density [SDS], hemoglobin, total protein, albumin, urea, creatinine, calcium, phosphorus, calcium phosphorus product, PTH, and alkaline phosphatase were measured at the baseline and after 12 months.

RESULTS

Growth velocity in 81 children during one-year rhGH treatment was 7.33 ± 2.63 cm (ΔSDS 0.36 ± 0.43). Height SDS increased significantly (-3.31 ± 1.12 vs. -2.94 ± 1.15, p < 0.001). Children on peritoneal dialysis (PD) (n = 51) were younger than children on hemodialysis (HD) (n = 30) (9.92 ± 3.72 vs. 12.32 ± 3.11 years, p = 0.003). ΔSDS did not differ between PD and HD children (0.40 ± 0.33 vs. 0.30 ± 0.47, p = 0.311). Growth velocity (ΔSDS) correlated with age at dialysis initiation (r=-0.30, p = 0.009), age at rhGH treatment initiation (r=-0.35, p = 0.002), skeletal age (r=-0.36, p = 0.002), BMI SDS (r=-0.27, p = 0.019), and PTH (r=-0.27, p = 0.017). No correlation between growth velocity and other parameters was observed.

CONCLUSIONS

Treatment with rhGH in children with ESRD is effective and safe irrespective of dialysis modality. Early initiation of rhGH therapy is a crucial factor determining response to the treatment in children with ESRD.

[Pulmonary embolism in a girl with nephrotic syndrome and factor V Leiden - case report]

Thromboembolic complications are found in 2-3% of children with nephrotic syndrome (NS); this increased risk is caused by hypovolemia, hemoconcentration, increased number and activity of platelets, hyperfibrinogenemia and loss of coagulation inhibitors. Risk is even higher in case of additional factors e.g. congenital thrombophilia.

CASE REPORT

Girl with NS aged 17 11/12 years was admitted to hospital due to respiratory tract infection with cough and back pain. NS started 9 months earlier and she had two bouts of disease, and was treated only with prednisone (current dose - 60 mg/48h). On admission she was without any abnormalities on auscultation, with BP 111/65 mmHg, HR 80 bpm, satO2 99%. Lab results showed the increase of WBC 18.3×103/μL, D-dimers 23038 μg/L and proteinuria 900 mg/dL. Other values of examined parameters were in normal limits. Chest X-ray and ECG were also normal. Presumptive diagnosis of pulmonary embolism was made and the patient was given 1000IU of antithrombin III and nadroparine (2x90IU/kg/24h s.c.). In ECHO the occlusion of left pulmonary artery and preserved blood flow in right were revealed. In angioCT clot nearly filling lumen of left pulmonary artery, clot in intermediate part of right pulmonary artery, and focus of pulmonary infarction in 10th segment of left lung were found. Doppler USG of lower limb veins did not reveal thrombi or perforator vein incompetence. Treatment with nadroparine was continued, and rapid improvement of clinical condition and disappearance of pain and cough were observed. Mycophenolate mofetil was added, which resulted in subsidence of proteinuria. Rivaroxaban was used in prophylaxis of recurrences of thromboembolism. Tests for thrombophilia revealed factor V Leiden in patient.

[Copeptin in children with chronic kidney disease]

Studies in adult patients suggest that copeptin (C-terminal fragment of antidiuretin propeptide) is related to kidney and cardiovascular diseases.

AIM

The aim was to assess copeptin concentration in children with chronic kidney disease (CKD).

MATERIALS AND METHODS

In a group of 38 children with CKD (age: from 4.70 to 18.00 mean 12.23±4.19 years) we evaluated: serum copeptin concentration [ng/mL], age, sex, etiology of CKD, presence of arterial hypertension (AH), medications, glomerular filtration rate (GFR), hemoglobin, calcium-phosphorus metabolism parameters, and lipids. Control group consisted of 38 healthy children aged from 5.51 to 18.0 mean 11.79±3.29 years.

RESULTS

Serum copeptin concentration did not differ between children with CKD and healthy children (0.72±0.34 vs. 0.84±0.33 [ng/mL], p=0.088). In children with CKD there were no differences in copeptin concentration depending on sex, presence of AH, and CKD grade. In children with CKD only positive correlation between copeptin and hemoglobin concentrations was found (r=0.35, p=0.031); no other significant correlations between copeptin and clinical and biochemical parameters including GFR were revealed. Also no significant correlations were found between copeptin and evaluated parameters in the control group.

CONCLUSIONS

In children copeptin concentration does not seem to be related to kidney function. Copeptin may be a marker of hydration status in children with chronic kidney disease. There is a need for further studies evaluating clinical significance of copeptin in children with chronic kidney disease.

Methods to evaluate arterial structure and function in children - State-of-the art knowledge

BACKGROUND

With increasing rates of hypertension, obesity, and diabetes in the pediatric population, wide available, and reproducible methods are necessary to evaluate arterial structure and function in children and adolescents.

METHODS

MEDLINE/Pubmed was searched for articles published in years 2012-2017 on methodology of, current knowledge on, and limitations of the most commonly used methods to evaluate central, proximal and coronary arteries, as well as endothelial function in pediatric patients.

RESULTS

Among 1528 records screened (including 1475 records from years 2012 to 2017) 139 papers were found suitable for the review. Following methods were discussed in this review article: ultrasound measurements of the intima-media thickness, coronary calcium scoring using computed tomography, arterial stiffness measurements (pulse wave velocity and pulse wave analysis, carotid artery distensibility, pulse pressure, and ambulatory arterial stiffness index), ankle-brachial index, and methods to evaluate vascular endothelial function (flow-mediated vasodilation, peripheral arterial tonometry, Doppler laser flowmetry, and cellular and soluble markers of endothelial dysfunction).

CONCLUSIONS

Ultrasonographic measurement of carotid intima-media thickness and measurement of pulse wave velocity (by oscillometry or applanation tonometry) are highly reproducible methods applicable for both research and clinical practice with proved applicability for children aged ≥6 years or with height ≥120cm. Evaluation of ambulatory arterial stiffness index by ambulatory blood pressure monitoring is another promising option in pediatric high-risk patients. Clearly, further studies are necessary to evaluate usefulness of these and other methods for the detection of subclinical arterial damage in children.

Quantum steering: a review with focus on semidefinite programming

Quantum steering refers to the non-classical correlations that can be observed between the outcomes of measurements applied on half of an entangled state and the resulting post-measured states that are left with the other party. From an operational point of view, a steering test can be seen as an entanglement test where one of the parties performs uncharacterised measurements. Thus, quantum steering is a form of quantum inseparability that lies in between the well-known notions of Bell nonlocality and entanglement. Moreover, quantum steering is also related to several asymmetric quantum information protocols where some of the parties are considered untrusted. Because of these facts, quantum steering has received a lot of attention both theoretically and experimentally. The main goal of this review is to give an overview of how to characterise quantum steering through semidefinite programming. This characterisation provides efficient numerical methods to address a number of problems, including steering detection, quantification, and applications. We also give a brief overview of some important results that are not directly related to semidefinite programming. Finally, we make available a collection of semidefinite programming codes that can be used to study the topics discussed in this article.

Renalase in Children with Glomerular Kidney Diseases

Studies suggest that renalase, a renal catecholamine-inactivating enzyme, plays a major role in the pathogenesis of kidney and cardiovascular diseases in adults. This study seeks to determine the role of renalase in children with glomerular kidney diseases. We evaluated the serum renalase, arterial stiffness, intima-media thickness, blood pressure, and clinical and biochemical parameters in 78 children (11.9 ± 4.6 years of age) with glomerulopathies such as idiopathic nephrotic syndrome (40 cases), IgA nephropathy (12 cases), Henoch-Schönlein nephropathy (12 cases), and other glomerulopathies (14 cases). The control group consisted of 38 healthy children aged 11.8 ± 3.3 years. The mean renalase was 25.74 ± 8.94 μg/mL in the glomerulopathy group, which was not significantly different from the 27.22 ± 5.15 in the control group. The renalase level did not differ among various glomerulopathies either. However, proteinuric patients had a higher renalase level than those without proteinuria (28.43 ± 11.71 vs. 24.05 ± 6.23, respectively; p = 0.03). In proteinuric patients, renalase correlated with daily proteinuria. In the entire glomerulopathy group, renalase correlated with age, systolic central blood pressure (BP), diastolic peripheral and central BP, mean peripheral and central BP; peripheral diastolic BP Z-score, glomerular filtration rate, cholesterol, triglycerides, and pulse wave velocity. We conclude that in children with glomerulopathies renalase, although basically not enhanced, may underlie blood pressure elevation and arterial damage.

Risk Factors for Decline of Residual Renal Function in Children Treated With Peritoneal Dialysis

♦ BACKGROUND: The aim of the study was to assess risk factors for residual renal function (RRF) decline in children during the first/second year of chronic peritoneal dialysis (PD). ♦ METHODS: The study group included 56 children with end-stage renal disease (ESRD) (age 10.13 ± 4.86 years), including 18 on continuous ambulatory PD (CAPD) and 38 on automated PD (APD), in whom we evaluated RRF (daily diuresis [mL/m2/24 h], residual glomerular filtration rate (rGFR) [mL/min/1.73 m2]), etiology of ESRD, PD fluid volume (mL/m2/24 h), glucose load (g/m2/24 h), ultrafiltration (mL/m2/24 h), peritoneal permeability (D/PCrea 4h, D/D0 Glu 4h), dialysis adequacy (twKt/V, twCCr [L/week/1.73 m2]), blood pressure (BP), biochemical parameters, and medications used. Duration of follow-up was 24 months. ♦ RESULTS: Mean diuresis before initiation of PD was 1,394.93 ± 698.37 (mL/m2/24 h), and mean rGFR was 7.41 ± 3.96 (mL/min/1.73 m2). The rate of daily diuresis decline was -529.34 ± 546.28 in the first year and -107.10 ± 291.54 (mL/m2/24 h) in the second year (p = 0.005), and the rate of rGFR decline was -3.35 ± 3.73 in the first year and -1.63 ± 1.85 (mL/min/1.73 m2) in the second year (p = 0.118). Eleven (19.64%) patients became anuric. In univariate analysis, the rate of daily diuresis decline in the first year was related to baseline diuresis (r = -0.29, p = 0.031), proteinuria (r = -0.43, p = 0.001), and systolic BP (r = -0.31, p = 0.020); 12-month changes (Δ0 - 12) in PD fluid volume (r = -0.37, p = 0.004), glucose load (r = -0.28, p = 0.035), and ultrafiltration (r = -0.38, p = 0.004); serum calcium-phosphorus product (r = -0.41, p = 0.002); and Δ0 - 12 body mass index (BMI) Z-score (r = 0.30, p = 0.024); while the rate of rGFR decline in the first year was related only to baseline rGFR (r = -0.57, p < 0.001). In multivariate analysis, significant predictors of the rate of daily diuresis decline in the first year were baseline diuresis (β = -0.386, p < 0.001) and proteinuria (β = -0.278, p = 0.017), mean systolic BP Z-score (β = -0.237, p = 0.027), and age at the onset of PD (β = -0.224, p = 0.037), while predictors of the rate of rGFR decline were baseline rGFR (β = -0.607, p < 0.001) and baseline proteinuria (β = -0.225, p = 0.046). In the second year, the only predictors of the rate of rGFR decline were D/D0 Glu 4h (r = 0.44, p = 0.033, univariate analysis) and rGFR at 12 months (β = -0.499, p = 0.044). ♦ CONCLUSION: The most important risk factors for rapid RRF decline in children during the first year of chronic PD include higher baseline daily diuresis and proteinuria, and additional factors are systolic BP and age at the onset of PD; while high baseline GFR and low peritoneal transport status may be the only important factors during the second year.

General Method for Constructing Local Hidden Variable Models for Entangled Quantum States

Entanglement allows for the nonlocality of quantum theory, which is the resource behind device-independent quantum information protocols. However, not all entangled quantum states display nonlocality. A central question is to determine the precise relation between entanglement and nonlocality. Here we present the first general test to decide whether a quantum state is local, and show that the test can be implemented by semidefinite programing. This method can be applied to any given state and for the construction of new examples of states with local hidden variable models for both projective and general measurements. As applications, we provide a lower-bound estimate of the fraction of two-qubit local entangled states and present new explicit examples of such states, including those that arise from physical noise models, Bell-diagonal states, and noisy Greenberger-Horne-Zeilinger and W states.

[Ocular toxocariasis in a boy with idiopathic nephrotic syndrome - a case report]

Toxocariasis is a common zoonosis caused by infection with Toxocara canis or cati larvae. Ocular toxocariasis is one of the forms of infestation found in 1/1,000 - 1/10,000 children. Children with idiopathic nephrotic syndrome (INS) are at high risk of infections, also parasitic infestations, which can, in turn, cause relapses of the disease.

A CASE REPORT

We present a case of a 6-year-old boy with steroiddependent nephrotic syndrome. The disease started at age of 2, the boy had 9 relapses of INS, and was treated with oral prednisone, levamisole, and cyclophosphamide. During hospitalization with Xth relapse of INS, he was screened for causes of recurrences and IgG antibodies against Toxocara were found. Fundoscopy revealed white, slightly elevated, and discoloured inflammatory lesions in right retina without inflammation in the vitreous. Ocular toxocariasis was diagnosed. The boy was treated for 7 days with albendazole in the dose of 15 mg/kg/24 h with simultaneous increase of the dose of prednisone to 1mg/kg/24 h. In control fundoscopic examinations there was no progression of ocular lesions.

CONCLUSIONS

In children on immunosuppressive treatment with possible exposure to animals or raw meet it is advisable to take serological tests for Toxocara infestation also in the absence of clinical symptoms of parasitic infection.

[Fibroblast growth factor 23 in chronic kidney disease in children]

Cardiovascular risk in children with chronic kidney disease (CKD) is many times higher compared to their healthy peers, and discovered in year 2000 fibroblast growth factor 23 (FGF23) may be one of the factors responsible. FGF23 together with its cofactor, α-Klotho protein, plays a pivotal role in calcium-phosphorus metabolism in patients with CKD by decreasing secretion of active metabolite of vitamin D and antagonizing phosphate resorption in renal tubules. Studies conducted in recent years revealed that FGF23 directly binds to its receptor on cardiomyocytes and promotes left ventricular hypertrophy. Clinical trials in children with CKD, similarly to adult studies, suggest a key role of this protein in development of calciumphosphorus disturbances. Single studies in small patient groups suggest also a significance of FGF23 in pathogenesis of cardiovascular alterations in this population. Further clinical trials investigating role of FGF23 in development of cardiovascular damage in larger groups of children are necessary, which may open new therapeutic options for these patients in future.

[Abdominal symptoms necessitating surgical intervention as the initial presentation of Henoch-Schönlein purpura in children - case reports]

Henoch-Schönlein purpura (HSP) is the most common pediatric autoimmune vasculitis. Gastrointestinal symptoms of HSP including abdominal pain, diarrhea, and vomiting may precede skin changes by several days. We present diagnostic challenges in two adolescents with HSP and severe abdominal symptoms necessitating surgical intervention before the development of skin changes.

CASE REPORT 1

A 15-year old boy with 7 day history of abdominal pain, and bloody vomiting (1-2 x per day) without diarrhea. A suspicion of acute appendicitis was raised and the boy was operated on the 7th day since the initial symptoms. The appendix showed some reactive inflammation and was removed during laparotomy which also revealed enlarged mesenteric lymph nodes and a modest amount of fluid in the pelvic cavity. During the first day after the surgery, skin changes typical for HSP developed on lower limbs and buttocks.

CASE REPORT 2

A 12-year old girl with 7 day history of abdominal pain, without diarrhea or vomiting. On the day of admission hemorrhagic rash appeared on lower limbs. Laparotomy was performed on 14th day after onset of abdominal pain - large amounts of serous, blood-stained fluid, massive dilation of small intestine with ecchymoses in mucous membrane, segmental infiltration and stiffening of intestinal wall were found. Normal appendix was removed.

CONCLUSIONS

Severe abdominal symptoms may precede skin changes in children with HSP, resulting in diagnostic and therapeutic challenges. When considering laparotomy in children with an atypical "acute abdomen" presentation, other manifestations of HSP should be sought.

Body weight changes in children with idiopathic nephrotic syndrome

BACKGROUND

Aim of the study was to evaluate factors affecting body mass change in children with idiopathic nephrotic syndrome (INS) during 6-months treatment of initial disease bout with glucocorticoids (GC).

MATERIAL AND METHODS

We studied 31 children with INS (22♂, 9♀, 3.6±1.8 years) treated during 6 months with GC due to initial INS bout and 31 control healthy children (18♂, 13♀, 4.0±1.8 years). Following factors were evaluated: body mass, body mass index (BMI), BMI Z-score, gender, age, gestational age at birth, birth weight, GC dose, parental age and BMI, time spent for TV/computer, physical activity, place of residence.

RESULTS

Mean initial BMI Z-score was 0.35±1.1 in children with INS and -0.11±1.5 in the control group, after 6 months 0.8±1.2 (P=0.049) and 0.07±1.5 (P=0.629), respectively. Δ0-6 BMI Z-score correlated with initial BMI Z-score (r=-0.45, P=0.001), maternal age (r=0.38, P=0.04), and paternal BMI (r=0.51, P=0.0037).

CONCLUSIONS

1. Initial 6-month GC therapy may result in body mass increase in children with INS. 2. Risk factors for body mass increase in children with INS during the first 6 months of therapy include low initial BMI, older maternal age and paternal obesity.

Detection of entanglement in asymmetric quantum networks and multipartite quantum steering

The future of quantum communication relies on quantum networks composed by observers sharing multipartite quantum states. The certification of multipartite entanglement will be crucial to the usefulness of these networks. In many real situations it is natural to assume that some observers are more trusted than others in the sense that they have more knowledge of their measurement apparatuses. Here we propose a general method to certify all kinds of multipartite entanglement in this asymmetric scenario and experimentally demonstrate it in an optical experiment. Our results, which can be seen as a definition of genuine multipartite quantum steering, give a method to detect entanglement in a scenario in between the standard entanglement and fully device-independent scenarios, and provide a basis for semi-device-independent cryptographic applications in quantum networks.

Quantum communications operate with shared multipartite entangled states, and this has to be certified in a setting where not all parties are trusted in the same way. Here the authors propose a method to certify multipartite entanglement in asymmetric scenarios and demonstrate it in an optical experiment.

PROCEEDING IN ACUTE KIDNEY INJURY IN ASPHYXIATED NEONATES--DIFFICULTIES AND SUCCESS

Acute kidney injury (AKI) is a common consequence of perinatal asphyxia reported in 30 to 70% cases. We present 4 full-term neonates with oliguric/anuric AKI caused by perinatal asphyxia requiring renal replacement therapy (RRT) and their long-term outcomes. Patient No. 1 was dialyzed for 12 days (continuous ambulatory peritoneal dialysis (CAPD)/continuous venovenous hemodiafiltration (CWHDF)), then was treated conservatively, and received pre-emptive kidney transplantation (KTx) at the age of 3 3/12 years. Patient No. 2 was treated with CAPD/automated peritoneal dialysis (APD) for 15 months, due to recovery of renal function, dialysis was withdrawn. He is now 8 5/12 years old and has chronic kidney disease (CKD) stage III. Patient No. 3 after 5 days of continuous arteriovenous hemofiltration (CAVH) required CAPD for 17 days. The child is now 8 4/12 years old and has CKD stage III. Patient No. 4, dialyzed from 3rd day of life for 51 months (CAVH followed by CAPD/APD), was given cadaver KTx at the age of 4 3/12 years. Psychomotor development is good in 2 patients, whereas patients No. 3 and 4 have tetraplegic spastic infantile cerebral palsy, severe mental retardation, and epilepsy.

CONCLUSIONS

Severe perinatal asphyxia with oliguric/anuric AKI is a risk factor for chronic kidney disease sometimes end-stage renal disease.

Effect of hypertension and antihypertensive medications on residual renal function in children treated with chronic peritoneal dialysis

PURPOSE

To evaluate the effect of hypertension (HTN) and antihypertensive medications (AHM) on residual renal function (RRF) in children on CAPD and APD.

MATERIAL/METHODS

We retrospectively evaluated underlying kidney disease, systolic and diastolic blood pressure (SBP/DBP), presence and control of HTN (SBP/DBP≥95th percentile), AHM, RRF (daily diuresis, residual glomerular filtration rate [rGFR]), biochemical parameters, BMI Z-score, and dialysis parameters during 12-month follow-up in 87 children (38 CAPD, 49 APD) aged 10.22±4.31 years. The rate of RRF loss was expressed as absolute and relative [%] reduction.

RESULTS

At baseline, HTN was found in 74.7% patients (CAPD/APD: 84.2%/67.3%, P=0.06), most commonly in HUS and least frequently in CAKUT. The proportion of CAPD/APD patients with poorly controlled HTN was 70.0%/63.3% (P=0.50). Relative daily diuresis loss in children with uncontrolled HTN was higher (P=0.017) compared to children with SBP/DBP <95th percentile. No effect of AHM on the rate of RRF loss was found. In multivariate analysis, absolute daily diuresis loss was related to baseline diuresis (β=-0.30, P<0.001) and proteinuria (β=-0.31, P=0.004); absolute rGFR loss to baseline rGFR (β=-0.73, P<0.001) and glucose load after 12 months (β=-0.36, P=0.02); relative daily diuresis loss to mean BMI Z-score (β=-0.44, P=0.04); and relative rGFR to baseline rGFR (β=-0.37, P<0.001) and SBP percentile (β=-0.21, P=0.045).

[The clinical significance of peritoneal transport in children during first year of peritoneal dialysis]

Peritoneal transport status is one of main prognostic factors in patients with end-stage renal disease (ESRD) treated with chronic peritoneal dialysis (PD). The aim of study was evaluation of influence of peritoneal transport status on selected clinical and biochemical parameters in children with ESRD in first year of PD treatment.

MATERIALS AND METHODS

52 children (mean age 10.3 ± 4.7 years) with preserved residual renal function (RRF) treated with PD were enrolled into the study. In all patients we evaluated in first 12 months of PD treatment: peritoneal equilibration test (PET): D/P (Crea 4h), D/D0 Glu 4h, age, sex, etiology of ESRD, blood pressure, RRF (daily diuresis [mL/kg/24h], residual GFR [mL/min/1.73 m2]), PD parameters, adequacy, rate of PD-related peritonitis, medications, and biochemical parameters.

RESULTS

Mean D/P (Crea 4h) was 0.65 ± 0.13, mean D/D0 glu 4h-0.38 ± 0.13. Patients were divided into 2 groups: H/HA (high/high-average) peritoneal permeability--26 (50.0%) and L/LA (low/low-average)--26 (50.0%) children. Patients with H/HA were significantly (P < 0.05): younger, had slower growth rate, higher systolic blood pressure, worse control of arterial hypertension, slower rates of rGFR and twCCr (total weekly clearance of creatinine) decline, higher incidence of peritonitis, lower total protein and albumin; tendency to lower hemoglobin (P = 0.07) compared to patients with L/LA.

CONCLUSIONS

High peritoneal permeability in children with ESRD treated with chronic peritoneal dialysis may be a risk factor for slower growth rate, systolic hypertension, peritonitis and metabolic disturbances: anemia, hypoproteinemia and hypoalbuminemia. Rate of GFR decline is slower in children with high peritoneal transport status.