Quality of life in children at different stages of chronic kidney disease in a developing country.

BACKGROUND: Children with chronic kidney disease (CKD) require comprehensive assessments, including medical and quality of life (QoL) evaluations. Few studies have been conducted in developing countries. METHODS: This cross-sectional study included 2-18-year-old patients who were categorized into 4 groups: the CKD stage 2-3, stage 4-5, stage 5 with dialysis (D), and kidney transplantation (KT) groups. QoL was measured using the Pediatric Quality of Life Inventory™ (PedsQL™) version 4.0; relationships between different factors and QoL were determined using multivariable linear regression analysis. RESULTS: Eighty-seven patients (mean age: 13.3 (4.1) years) were included. The self-reported total scores were 77.5 (12.5), 78.9 (11.2), 77.4 (16.2), and 76.1 (10.9) in the stage 2-3, stage 4-5, stage 5D and KT groups, respectively. Parent-reported scores showed a weak-to-moderate correlation with self-reported scores (r = 0.12-0.42), with total scores of 71.8 (12.7), 69.5 (14.9), 63.4 (14.8), and 70.8 (18.1) in the stage 2-3, 4-5, 5D and KT groups, respectively. Multivariable linear regression revealed that the parent-reported score in the stage 5D group was 15.92 points lower than that in the stage 2-3 group (p = 0.02); the score in the low maternal education group was 10.13 points lower than that in the high maternal education group (p = 0.04). CONCLUSIONS: Parent-reported scores showed weak-to-moderate correlation with self-reported scores. Patients with CKD stage 5D and patients with low maternal education had lower QoL. Regular QoL assessment is recommended for patients with advanced CKD and those with socioeconomic vulnerabilities.

The incidence and factors associated with dysnatremia in children with acute gastritis/gastroenteritis.

BACKGROUND: The incidence of dysnatremia in children with acute gastritis/gastroenteritis varies, and factors associated with either dysnatremia or hyponatremia at presentation have not been identified clearly. METHODS: This retrospective study included patients aged 1 month to 18 years hospitalized for community-acquired acute gastritis/gastroenteritis from January to October 2016. Factors associated with dysnatremia at presentation were identified using multivariable analysis. RESULTS: Among the 304 children included, the median age was 2.2 (1.0, 4.2) years. The incidence of dysnatremia at presentation was 17.1% (hyponatremia 15.8%; hypernatremia 1.3%). Patients who had moderate (p = 0.03) and severe dehydration (p = 0.04) and presented with vomiting and diarrhea simultaneously (p = 0.03) were associated with dysnatremia at presentation. Patients presented with vomiting and diarrhea simultaneously was associated with hyponatremia at presentation (p = 0.02). CONCLUSIONS: Dysnatremia was common in children with acute gastritis/gastroenteritis. Moderate to severe dehydration and the presence of vomiting and diarrhea simultanously were significantly associated with dysnatremia at presentation. Furthermore, presenting with vomiting and diarrhea silmutaneously was associated with hyponatremia at presentation. Serum electrolytes should be monitored in patients with those conditions.

Effect of peritoneal dialysate on bioelectrical impedance analysis variability in pediatric patients receiving peritoneal dialysis.

BACKGROUND: Previous adult studies have yielded conflicting results regarding whether the presence (D +) or absence (D-) of peritoneal dialysate affects the accuracy of bioelectrical impedance analysis (BIA) measurements. The aim of this study was to investigate whether the accuracy of BIA data varies between D + and D- measurements in children. METHODS: This cross-sectional study recruited chronic kidney disease stage 5 patients aged 3 to 18 years who received peritoneal dialysis. Body composition was assessed by multifrequency BIA, and values were compared between D + and D- measurements using the intraclass correlation coefficient (ICC). RESULTS: Fifty paired BIA measurements were collected from 18 patients with a mean age of 13.6 ± 4.1 years and a mean dialysate fill volume of 1,006 ± 239.7 ml/m2. Sixteen out of 17 BIA parameters (94.1%) exhibited excellent correlations between D + and D- measurements (ICC values = 0.954, 0.998). There was a trend of increased fluid status, including extracellular water, edema index, and overhydration, in D + measurements, with mean differences (95% CIs) of 0.5 (0.4, 0.6) L, 0.002 (0.001, 0.002), and 0.1 (0.1, 0.2) L, respectively. Soft lean mass and fat-free mass were higher in D + measurements, with mean differences (95% CIs) of 1.4 (1.2, 1.6), and 1.6 (1.4, 1.8) kg, respectively. In addition, patients older than 10 years had a stronger correlation between D + and D- measurements than younger patients. CONCLUSIONS: A total of 94.1% of BIA parameters exhibited excellent correlations between D + and D- measurements, especially patients older than 10 years. We recommend that BIA measurements be collected from children regardless of the presence of peritoneal dialysate.

Dysnatremia and subsequent sodium level changes following various intravenous treatments in infants with acute gastroenteritis.

Acute gastroenteritis is one of the main causes of electrolyte imbalance in infants. We aimed to determine the frequency of and factors associated with dysnatremia at presentation and establish the ideal intravenous treatment scheme. The records of hospitalized infants aged 1-12 months with community-acquired acute gastroenteritis between January 2017 and March 2021 were retrospectively reviewed. Factors associated with dysnatremia at presentation were analyzed by multivariable logistic regression analysis. Subsequent sodium levels 4-24 h after intravenous fluid treatments, which were categorized into 2 groups, were determined in the subgroup of infants with normal sodium levels at presentation. A total of 347 infants with a median age of 8.0 (5.0-10.0) months were included. The frequency of dysnatremia at presentation was 14% (hyponatremia 12% and hypernatremia 2.0%). Severe dehydration was associated with dysnatremia at presentation (p = 0.048). Among 68 infants with normal sodium levels at presentation, the median sodium change was highest in the 5% dextrose in saline group, with changes of + 3 (0.5-5) and + 1 (- 2 to 2) mmol/L in infants who received 5% dextrose in saline and 5% dextrose in 1/3-1/2 saline, respectively (p = 0.001). Four out of 47 infants (8.5%) developed hyponatremia while receiving 5% dextrose in 1/3-1/2 saline. None of those who received 5% dextrose in saline developed subsequent dysnatremia.   Conclusion: The frequency of dysnatremia at presentation among infants with acute gastroenteritis was 14%. Severe dehydration was associated with dysnatremia at presentation, so electrolyte levels need to be assessed in these patients. The use of isotonic solution did not promote acquired dysnatremia. This study supports once more that current guidelines recommending isotonic solution for children, and, especially, infant rehydration, are important also for infants in Thailand. What is Known: • There were a wide variation in the incidence of dysnatremia at presentation in children with acute gastroenteritis in previous pediatric series. • The AAP guidelines recommend using isotonic solution in children with acute illness from 28 days to 18 years of age to prevent acquired hyponatremia. What is New: • The incidence of dysnatremia at presentation in infants with acute gastroenteritis was 14% (hyponatremia 12% and hypernatremia 2.0%). • The use of isotonic solution did not promote acquired dysnatremia in infants with acute gastroenteritis.

Clinicopathological Correlation of Polyomavirus Nephropathy in Renal Allograft Recipients According to the Banff 2018 Classification.

BACKGROUND: Polyomavirus nephropathy (PVN) is a rare kidney disease caused by the BK virus, a strain of polyomavirus. The disease primarily affects transplant recipients, which is related to intensive immunosuppression protocol and can lead to kidney allograft failure. OBJECTIVES: The objective of this study is to analyze histopathological features of PVN using the Banff 2018 PVN classification and to determine clinical features and outcomes of patients with PVN in each histologic class. MATERIALS AND METHODS: The study included 44 patients who had been diagnosed with PVN by renal allograft biopsy in a large tertiary care hospital in Thailand from January 2011 to January 2020. The kidney biopsy slides were reviewed for Banff 2018 PVN classification and other histologic features. Patient demographic information, clinical data, and laboratory results were retrospectively collected. RESULTS: Nine (20.45%), 27 (61.36%), and eight (18.18%) cases of PVN were Class I, Class II, and Class III, respectively. The time from transplant to PVN diagnosis for Classes I, II, and III was four, 19, and 33.5 months, respectively. Class III had the worst clinical outcomes in terms of deterioration of allograft function, the lowest rate of resolution, and the highest rate of graft failure. CONCLUSIONS: PVN classification provides prognostic information in renal allograft biopsy. Our study confirmed the validity of the three-tier histologic PVN classification put forward by the Banff Working Group in 2018.

Model for predicting high-grade vesicoureteral reflux in young children presenting with febrile urinary tract infection.

INTRODUCTION: High-grade vesicoureteral reflux (VUR) is associated with long-term renal outcome, and can be missed if voiding cystourethrogram (VCUG) is not performed. The current febrile urinary tract infection (UTI) guidelines have narrowed down the indications for VCUG. This study aimed to determine the predictors and develop a model to predict high-grade VUR (grade III-V) in young children presenting with febrile UTI. METHODS: We retrospectively reviewed 324 children aged 2-60 months who presented with first or recurrent febrile UTI and underwent both renal and bladder ultrasonography (RBUS) and VCUG during 2004-2013. Multivariate logistic regression was used to identify independent predictors of high-grade VUR, and a predictive model and scoring system were developed. Sensitivity and specificity of the predictors were evaluated. RESULTS: Sixty-two (67.4%) of 92 children with VUR were high-grade VUR. The independent risk factors for high-grade VUR were recurrent UTI (p < 0.001), non-Escherichia coli (non-E. coli) pathogen (p = 0.011), and abnormal RBUS (p < 0.001) including pelvicalyceal dilation only (p = 0.003), and with ureteric dilation (p < 0.001). Abnormal RBUS showed highest sensitivity (58.1%), while ureteric dilation had highest specificity (96.6%) to predict high-grade VUR. Combination of these predictors improved the specificity but decreased the sensitivity. The prediction score was calculated, as follows: recurrent UTI = 3 points + non-E. coli = 1 point + pelvicalyceal dilation only = 1 point + pelvicalyceal and ureteric dilation = 3 point. A cutoff score of 1 showed sensitivity of 82.3% and specificity of 63.7%. The specificity would increase (87.8, 92.7, 97.7, 100, 100, and 100%) for higher scores of 2, 3, 4, 5, 6 and 7, respectively. DISCUSSION: High-grade VUR could be predicted by simple model using single or combined predictors. Sensitivity and specificity varied according to each predictor. The specificity of ureteral dilation was as high as recurrent UTI. The weighing score for each presenting predictor and the summation of the scores provided more detailed in sensitivity and specificity. CONCLUSIONS: Children with febrile UTI who have the predictor(s) of high-grade VUR are recommended to undergo VCUG. The high-grade VUR prediction score may help for decision-making regarding whether to perform VCUG in a particular child.

Prevalence of cognitive dysfunction and its risk factors in children with chronic kidney disease in a developing country.

BACKGROUND: Chronic kidney disease (CKD) is associated with cognitive dysfunction. Cognitive function in children with CKD residing in developing countries has not been previously reported. METHODS: This cross-sectional study included children aged 6-18 years with CKD stages 2-5D and kidney transplant. Cognitive function was assessed by WISC-V for children from 6-16 years of age. In adolescents 17-18 years of age, WAIS-III was used. Factors associated with cognitive dysfunction were identified using multivariable regression analysis. RESULTS: Thirty-seven children with median age 13.9 (11.3-15.7) years were recruited. The median full-scale intelligence quotient (FSIQ) was 83.0 (71.0-95.0). Below-average cognitive function (FSIQ <90) was identified in 24 children (64.8%), 24.3% of whom had cognitive impairment (FSIQ <70). Most children (94.6%) scored lower than average on at least 1 cognitive domain. Kidney replacement therapy (p = 0.03) and low family income (p = 0.02) were associated with below-average cognitive function in multivariable logistic regression analysis. Children who left school and low family income were significantly associated with cognitive function. The FSIQ of children who had left school was 12.94 points lower than the educated group (p = 0.046). In addition, every 10,000 Thai Baht (approximately 330 United States dollars) increase in family income correlated with 1.58 increase in FSIQ (p = 0.047). CONCLUSION: Cognitive dysfunction was commonly found in children with CKD. Socioeconomic factors, particularly school attendance and family income, were associated with cognitive dysfunction. Cognitive evaluation is suggested for children with CKD who have socioeconomic risk factors. "A higher resolution version of the Graphical abstract is available as Supplementary information."

Incidence of Cytomegalovirus DNAemia in Pediatric Kidney Transplant Recipients After Cessation of Antiviral Prophylaxis.

BACKGROUND: Late cytomegalovirus (CMV) infection can occur after cessation of viral prophylaxis in kidney transplant recipients, yet, timing of infection is unclear and longer duration of prophylaxis may be warranted. METHODS: We conducted a retrospective cohort study of 86 children (35 CMV donor seropositive, recipient seronegative [D + R-] and 51 CMV recipient seropositive [R+]) younger than 18 years who received a kidney transplant between January 2002 and June 2014 and were treated with antiviral prophylaxis for 3 months after transplantation. Incidence of CMV DNAemia and CMV disease was determined using Kaplan-Meier analyses and risk factors were assessed using Poisson regression. RESULTS: Of the 86 children, 61.6% were male and median age at transplant was 13.4 years (interquartile range [IQR], 8.9-15.6) with a median follow-up of 35.2 months (IQR, 18.0-54.5). Incidence of CMV DNAemia within the first 3 months after prophylaxis cessation in CMV D + R- and CMV R+ children was 22.9% and 23.5% and incidence of CMV disease was 11.4% and 0%, respectively. Cumulative incidence of CMV DNAemia in both groups was similar (31.4%). Children who received antithymocyte globulin were more likely to develop CMV DNAemia compared with those who received anti-IL-2 (IRR, 2.98; 95% confidence interval, 1.41-6.30) after controlling for age, sex, Epstein-Barr Virus serostatus and rejection. CONCLUSIONS: This study demonstrates a high incidence of CMV infection after cessation of antiviral prophylaxis. These results support extension of antiviral prophylaxis beyond 3 months and/or intensive viral load monitoring to reduce risk of CMV infection in D + R- and R+ children, especially those receiving antithymocyte globulin.

Tacrolimus in steroid resistant and steroid dependent childhood nephrotic syndrome.

OBJECTIVE: To evaluate the efficacy of tacrolimus (Tac) in steroid resistant and steroid dependent nephrotic syndrome (NS) in children. MATERIAL AND METHOD: Retrospective chart reviews of 18 children from outpatient clinic at the Department of Pediatrics, Faculty of Medicine Siriraj Hospital were diagnosed with steroid resistant (SR) and steroid dependent (SD) NS during 2002-2008 were enrolled in the present study RESULTS: The boy to girl ratio was 2:1. The mean age at diagnosis was 6.0 years (1-14.4 years). There were nine SR and nine SDNS. Nine patients had focal segmental glomerulosclerosis (FSGS), 4 IgMnephropathy and two had minimal change diseases (MCD). Three children did not receive renal biopsy. All patients received prednisolone at the start of Tac. The average time from the diagnosis to initiation of Tac was 3.5 years (0.2-14years). The mean duration of Tac treatment was 1.3 year (0.3-6.2 years). The average Tac trough blood level was 4.09 mcg/L (1.3-9.9 mcg/L). The average dosage of Tac was 0.09 mg/kg/day (0.03-0.2 mg/kg/day). Thirteen (72.2%) children achieved complete response (CR). Five (27.80%) children did not respond to Tac. Nine (69.2%) children could stop prednisolone whereas four (30.8%) could lower prednisolone doses. The mean time to achieve CR was 24.6 days (0.1-3 months). The mean follow up period was 3.1 years (0.2-6.4 years). There was no change in an estimation of glomerular filtration rate (eGFR). In SRNS, there were CR in four (44.4%) and five (55.6%) children that FSGS did not respond to Tac. In SDNS, all responded to Tac and four (44.4%) children relapsed while on Tac and had upper respiratory tract infection (URI). CONCLUSION: Tac is well-tolerated and effective treatment for SR and SDNS.