[Development of nephrotic syndrome in a patient with Hashimoto's Thyroiditis]. / Desarrollo de Síndrome nefrótico en paciente con Tiroiditis de Hashimoto.

The development of nephrotic syndrome in concomitance with Hashimoto's thyroiditis is an in frequent association in the pediatric age. OBJECTIVE: To report an infrequent complication of au toimmune thyroiditis, such as the appearance of nephrotic syndrome. CLINICAL CASE: A 10-year-old patient presenting with nephrotic syndrome and goiter. A history of autoimmune thyroiditis and un treated hypothyroidism was detected. Corticosteroid and hormone replacement therapy (levothyro- xine) is started, achieving a good clinical and laboratory response. CONCLUSION: Autoimmune thyroi ditis impacts renal physiology through immunological and non-immunological mechanisms. At the same time, renal repercussions can affect thyroid function. The importance of this communication lies in reporting an infrequent complication of autoimmune thyroiditis, such as the appearance of nephrotic syndrome.

[Recommendations on diagnosis, management and study of the urinary tract infection in pediatrics. Nephrology Branch of the Chilean Society of Pediatrics. Part 1]. / Recomendaciones sobre diagnóstico, manejo y estudio de la infección del tracto urinario en pediatría. Rama de Nefrología de la Sociedad Chilena de Pediatría. Parte 1.

Urinary tract infection (UTI) is one of the most frequent bacterial infection in pediatrics. However, its diagnosis and management can be complicated due to the nonspecific clinical presentation, the difficulty of exams interpretation, especially in younger children, and an uncertain prognosis regar ding renal damage. In recent years, significant worldwide change has come in treatment, diagnosis, and images studies, we have decided to update the current recommendations on UTI management published by the Pediatric Nephrology branch of Chilean Pediatrics Society in previous years. The purpose of these recommendations is to reduce the variability of clinical practice in management of UTI in our pediatric population, favoring diagnostic and therapeutic interventions in the most ap propriate way, improving detection and management of structural pathology and other risk factors of renal damage, avoiding unnecessary actions in children with low risk. This first part includes diag nosis and treatment recommendations of urinary tract infection in pediatric age. In the second part the study, prevention and monitoring of urinary tract in pediatric age is detailed.

Recomendaciones sobre diagnóstico, manejo y estudio de la infección del tracto urinario en pediatría: rama de Nefrología de la Sociedad Chilena de Pediatría. Parte 1 / Recommendations on diagnosis, management and study of the urinary tract infection in pediatrics: nephrology Branch of the Chilean Society of Pediatrics. Part 1

Resumen: La infección del tracto urinario (ITU) es una de las infecciones bacterianas mas frecuentes en la edad pediátrica, pero su diagnóstico y manejo se pueden ver complicados por lo inespecífico de sus sín tomas y signos de presentación, la dificultad en la interpretación de los exámenes, especialmente en niños mas pequeños, y por un pronóstico respecto a daño renal muchas veces incierto. En los últimos años, se ha evidenciado una modificación significativa en el enfoque diagnostico y terapéutico de esta patología, surgiendo la necesidad de actualizar las recomendaciones previas. El propósito de esta re vision es contribuir a reducir la variabilidad de la práctica clínica en el manejo de ITU en la población pediátrica, mejorando la detección y manejo de la patología estructural y otros factores de riesgo de daño renal, evitando acciones innecesarias en aquellos niños con bajo riesgo. En esta primera parte, se presentan las recomendaciones en cuanto a diagnóstico y manejo de la ITU en pediatría. En la segunda parte se detalla su estudio, prevención y seguimiento.

Abstract: Urinary tract infection (UTI) is one of the most frequent bacterial infection in pediatrics. However, its diagnosis and management can be complicated due to the nonspecific clinical presentation, the difficulty of exams interpretation, especially in younger children, and an uncertain prognosis regar ding renal damage. In recent years, significant worldwide change has come in treatment, diagnosis, and images studies, we have decided to update the current recommendations on UTI management published by the Pediatric Nephrology branch of Chilean Pediatrics Society in previous years. The purpose of these recommendations is to reduce the variability of clinical practice in management of UTI in our pediatric population, favoring diagnostic and therapeutic interventions in the most ap propriate way, improving detection and management of structural pathology and other risk factors of renal damage, avoiding unnecessary actions in children with low risk. This first part includes diag nosis and treatment recommendations of urinary tract infection in pediatric age. In the second part the study, prevention and monitoring of urinary tract in pediatric age is detailed.

The obese child in the Intensive Care Unit. Update. / El niño obeso en la Unidad de Cuidados Intensivos. Puesta al día.

Given that childhood obesity is an epidemic, the frequency of critically-ill patients who are overweight or obese seen at intensive care units has increased rapidly. Adipose tissue is an endocrine organ that secretes a number of protein hormones, including leptin, which stands out because it regulates adipose tissue mass. The presence of arterial hypertension, metabolic syndrome, diabetes mellitus, respiratory disease and chronic kidney disease may become apparent and complicate the course of obese pediatric patients in the Intensive Care Unit. Obesity management is complex and should involve patients, their families and the medical community. It should be coordinated with comprehensive government health policies and implemented in conjunction with a change in cultural context.

Actualmente, la obesidad infantil constituye una epidemia. La frecuencia de pacientes críticos con sobrepeso u obesidad ha aumentado rápidamente en las unidades de cuidados intensivos. El tejido adiposo es un órgano endocrino que secreta varias hormonas proteicas, entre las que se destaca la leptina, la cual es reguladora de su masa. La presencia de hipertensión arterial, síndrome metabólico, diabetes mellitus, enfermedades respiratorias y enfermedad renal crónica se puede manifestar en el paciente pediátrico obeso durante su estadía en la Unidad de Cuidados Intensivos y complicar su evolución. El tratamiento de la obesidad es complejo y debe involucrar al paciente, a su familia y a la comunidad médica. Debe realizarse en coordinación con políticas sanitarias gubernamentales integrales y en conjunto con un cambio de marco cultural.

Síndrome hemolítico urémico en Chile: presentación clínica, evolución y factores pronósticos / Hemolytic-uremic syndrome in Chile: clinical features, evolution and prognostic factors

Background: Hemolytic-uremic syndrome (HUS) is characterized by acute renal failure, microangiopathic hemolytic anemia and thrombocytopenia. Aim: To describe the characteñstics ofpatients with the diagnosis ofHUS in Chile, and to identify the most reliable early predictors oímorbidity and moñality. Material and methods: The clinical records ofpatients with HUS aged less than 15 years, attended between January 1990 and December 2003 in 15 hospitals, were reviewed. Demographic, clinical, biochemical, hematological parameters, morbidity and mortality were analyzed. Results: A cohort of 587 patients aged 2 to 8 years, 48 percent males, was analyzed. Ninety two percent had diarrhea. At the moment of diagnosis, anuria was observed in 39 percent of the patients, hypertension in 45 percent and seizures in 17 percent. Forty two percent required renal replacement therapy (RRT) and perítoneal dialysis was used in the majoríty of cases (78 percent). The most frequently isolated etiological agentwas Escherichia coli. Mortality rate was 2.9 percent in the acute phase of the disease and there was a positive correlation between mortality and anuria, seizures, white blood cell count (WCC) >20.000/mm³ and requirements of renal replacement therapy (p <0.05). Twelve percent of patients evolved to chronic renal failure and the risk factors during the acute phase were the need for renal replacement therapy, anuria, WCC >20.000/mm³, seizures and hypertension. Conclusions: The present study emphasizes important clinical and epidemiological aspeets ofHUSin a Chilean pediatricpopulation.

[Hemolytic-uremic syndrome in Chile: clinical features, evolution and prognostic factors]. / Síndrome hemolítico urémico en Chile: presentación clínica, evolución y factores pronósticos.

BACKGROUND: Hemolytic-uremic syndrome (HUS) is characterized by acute renal failure, microangiopathic hemolytic anemia and thrombocytopenia. AIM: To describe the characteristics of patients with the diagnosis of HUS in Chile, and to identify the most reliable early predictors of morbidity and mortality. MATERIAL AND METHODS: The clinical records of patients with HUS aged less than 15 years, attended between January 1990 and December 2003 in 15 hospitals, were reviewed. Demographic, clinical, biochemical, hematological parameters, morbidity and mortality were analyzed. RESULTS: A cohort of 587 patients aged 2 to 8 years, 48% males, was analyzed. Ninety two percent had diarrhea. At the moment of diagnosis, anuria was observed in 39% of the patients, hypertension in 45% and seizures in 17%. Forty two percent required renal replacement therapy (RRT) and peritoneal dialysis was used in the majority of cases (78%). The most frequently isolated etiological agent was Escherichia coli. Mortality rate was 2.9% in the acute phase of the disease and there was a positive correlation between mortality and anuria, seizures, white blood cell count (WCC)>20.000/mm3 and requirements of renal replacement therapy (p<0.05). Twelve percent of patients evolved to chronic renal failure and the risk factors during the acute phase were the need for renal replacement therapy, anuria, WCC>20.000/mm3, seizures and hypertension. CONCLUSIONS: The present study emphasizes important clinical and epidemiological aspects of HUS in a Chilean pediatric population.

[Renal scars after one year of follow up in children with a first episode of acute pyelonephritis]. / Cicatriz renal detectada mediante cintigrama renal DMSA en niños con primera pielonefritis aguda: estudio de factores de riesgo.

BACKGROUND: Acute pyelonephritis in children can leave a kidney scar that eventually can lead to hypertension or renal failure. 99mTc-dimercaptosuccinic acid renal scintigraphy (RC DMSA) is a widely accepted technique to assess children with acute pyelonephritis. AIM: To evaluate the presence of residual kidney scars detected through RC DMSA, in children with a first episode of acute pyelonephritis. PATIENTS AND METHODS: Clinical records of children with a first episode of acute pyelonephritis that were assessed within seven days of the episode with RC DMSA were reviewed. Children were considered eligible if they did not have a new episode of acute pyelonephritis and a second RC DMSA, one year after the first episode, was performed. The presence or absence of a renal scar after one year was associated to demographic, scintigraphy and laboratory variables. RESULTS: Fifty nine children, aged 1 month to 10 years, 35 females, were studied. Thirty nine percent had a renal scar in the scintigraphy perfomed after one year of follow up. The presence of a scar was correlated with a C reactive protein over 130 mg/dl and an altered relative renal function (below 44%), during the acute phase. CONCLUSIONS: A high C reactive protein and alterations of relative renal function during the acute phase of acute pyelonephritis in children, may be risk factors for the development of renal scars in the long term follow up.

Cicatriz renal detectada mediante cintigrama renal DMSA en niños con primera pielonefritis aguda: estudio de factores de riesgo / Renal scars after one year of follow up in children with a first episode of acute pyelonephritis

Background: Acute pyelonephritis in children can leave a kidney scar that eventually can lead to hypertension or renal failure. 99mTc-dimercaptosuccinic acid renal scintigraphy (RC DMSA) is a widely accepted technique to assess children with acute pyelonephritis. Aim: To evaluate the presence of residual kidney scars detected through RC DMSA, in children with a first episode of acute pyelonephritis. Patients and methods: Clinical records of children with a first episode of acute pyelonephritis that were assessed within seven days of the episode with RC DMSA were reviewed. Children were considered eligible if they did not have a new episode of acute pyelonephritis and a second RC DMSA, one year after the first episode, was performed. The presence or absence of a renal scar after one year was associated to demographic, scintigraphy and laboratory variables. Results: Fifty nine children, aged 1 month to 10 years, 35 females, were studied. Thirty nine percent had a renal scar in the scintigraphy perfomed after one year of follow up. The presence of a scar was correlated with a C reactive protein over 130 mg/dl and an altered relative renal function (below 44%), during the acute phase. Conclusions: A high C reactive protein and alterations of relative renal function during the acute phase of acute pyelonephritis in children, may be risk factors for the development of renal scars in the long term follow up.

Trasplante renal pediátrico: la experiencia de un centro / Pediatric kidney transplantation: a single center experience

El trasplante renal es la mejor alternativa para el tratamiento de la insuficiencia renal crónica terminal. En el caso de los niños, junto con mejorarles significativamente la calidad de vida, contribuye a la normalización del desarrollo pondoestatural. Los trasplantes renales se iniciaron en el Hospital San Juan de Dios a fines del 70. Hasta la fecha se han efectuado 285, y 64 en pacientes pediátricos. El objetivo de ésta presentación fue conocer nuestros resultados en términos de morbimortalidad, sobrevida de injertos renales y comparar estas cifras con otras publicaciones. Se efectuó un análisis retrospectivo de las fichas clínicas de todos los receptores. El promedio de edad fue de 11 años, con un 94 por ciento de los receptores con más de 20 kg de peso. Un 73 por ciento recibió un injerto cadavérico, con un promedio de 23 horas de isquemia fría. La primera causa de insuficiencia renal crónica fue la hipoplasia y displasia congénita (36 por ciento). 92 por ciento de los receptores estaban en diálisis al momento del trasplante. La trombosis arterial estuvo presente en 4,6 por ciento. Un 7 por ciento de los injertos se perdieron por abandono de inmunosupresión. Un 17 por ciento requirió diálisis post-trasplante, transitoria,. La sobrevida actuarial global de los injertos renales fue de 83 por ciento al primer año y 77 por ciento al tercer y quinto años. El trasplante renal pediátrico representa más del 20 por ciento de nuestros receptores. Los resultados en términos de complicaciones y sobrevida actuarial de los injertos, son parecidos a los publicados en la literatura. A futuro, debemos trasplantar a éstos niños a edades más tempranas y antes de que ingresen a diálisis.

Síndrome hemolítico urémico en Santiago de Chile: evolución de la función renal y factores pronósticos / Hemolytic uremic syndrome (HUS), prognostic factors and follow up of renal function, in Santiago, Chile

Introducción: El Síndrome Hemolítico Urémico (SHU) se caracteriza por falla renal aguda, anemia hemolítica microangiopática y trombocitopenia; es la causa más frecuente de insuficiencia renal aguda en la infancia. Objetivo: a) Describir las características actuales del cuadro inicial de SHU en nuestro medio y comparar con lo descrito anteriormente; b) Describir la evolución a 1 año plazo y evaluar posibles factores pronósticos de función renal. Sujetos y Métodos: Se estudiaron variables demográficas, presentación clínica, exámenes bioquímicos y hematológicos, en 374 pacientes con SHU diagnosticados entre Enero 1990 a Diciempe 2002 en 9 hospitales de la Región Metropolitana; se evaluó además función renal al año de seguimiento en una muestra de 213 pacientes y se identificaron factores pronósticos de insuficiencia renal crónica y mortalidad utilizando el análisis de regresión logística. Resultados: Se analizaron 374 pacientes, 50,5 por ciento mujeres, 65,5 por ciento de la Región Metropolitana, edad promedio 1,5 ± 1,4 años (0,2 a 8); 91 por ciento presentó diarrea, 31 por ciento ocurrió en verano, al ingreso 57 por ciento presentó anuria, 43,3 por ciento hipertensión arterial y convulsiones 23 por ciento. Al alta 28 por ciento persistía hipertenso. Las terapias de sustitución renal utilizadas fueron: diálisis peritoneal (50 por ciento), hemodiafiltración (6 por ciento) y hemodiálisis (3 por ciento); recibió plasmaféresis 1 por ciento. Se aisló agente etiológico en 17 por ciento, siendo en 69 por ciento E. coli enterohemorrágica. La mortalidad fue de 2,7 por ciento, siendo la causa principal la falla orgánica múltiple. En el seguimiento al año: 80 por ciento mantuvo función renal normal, 14 por ciento presento deterioro de la función renal, 6 por ciento proteinuria y 4 por ciento hipertensión. Se encontró significativo como factor pronóstico de daño renal: hipertensión arterial (p < 0,0001), necesidad de peritoneodiálisis y hemodiálisis (p: 0,001, p: 0,0015 respectivamente), anuria (p: 0,005) y convulsiones (p: 0,01). Se correlacionó con mortalidad en la etapa aguda: convulsiones, requerimiento de hemodiafiltración y plasmaféresis, (p < 0,0001, p: 0,0001 y p < 0,0001 respectivamente).

Cintigrama renal DMSA en niños con primera pielonefritis aguda: correlación con exámenes de laboratorio, ecografía y la presencia de reflujo vésico ureteral / Tc 99M DMSA scintigraphy in children with a first episode of pyelonephritis

Background: Tc99m DMSA (dimercaptosuccinic acid) scintigraphy has a high sensitivity for the detection of cortical kidney damage. Aim: To evaluate the Tc99m DMSA renal scintigraphy in children with a first episode of acute pyelonephritis and its association with laboratory parameters, kidney ultrasound and vesicoureteral reflux. Patients and methods: We studied 143 children (age range 8 days, 12 years, 66 percent female) hospitalized with the clinical diagnosis of acute pyelonephritis (first episode) with a positive urine culture and a renal scintigraphy performed within seven days of diagnosis. DMSA was considered the gold standard for the detection of cortical lesions. Its results were related to the presence of fever, C-reactive protein (CRP), erythrocyte sedimentation rate (VHS), white blood count (WBC), ultrasound examination and vesicoureteral reflux. Results: Seventy nine percent of the population had an abnormal DMSA scan. There were no differences between sex, age and laboratory parameters in children with normal or abnormal DMSA scans, except for CRP (p <0.005). Ultrasound was coincident with the scan in 32 percent of patients. Eighteen percent had vesicoureteral reflux. Conclusions: There is a high proportion of abnormal DMSA scans in children with a first episode of acute pyelonephritis (Rev Méd Chile 2004; 132: 58-64).