Dysfunctional voiding: the importance of non-invasive urodynamics in diagnosis and treatment.

In Dysfunctional voiding, failure of the external sphincter-pelvic floor complex to relax during micturition results in bladder outflow obstruction with a spectrum of presentation from more benign lower urinary tract dysfunction including recurrent urinary tract infections, to significant upper tract pathology and end-stage renal failure. There is no underlying neurological or anatomical cause and the condition is postulated to be a largely learnt behavior. Diagnosis relies on non-invasive urodynamics and in particular uroflowmetry, plus or minus EMG, which is also used in biofeedback, the mainstay of treatment. The etiology, presentation, diagnosis, and treatment with particular emphasis on non-invasive urodynamics are covered.

Investigating the role of cardiovascular biomarkers in children with pre-dialysis chronic kidney disease: a substitute to echocardiography to detect increased left ventricular mass?

BACKGROUND: Children with chronic kidney disease (CKD) are at increased risk of future cardiovascular (CV) events. Our aim in this prospective single-centre cross-sectional analysis was to assess the relationship of a novel panel of CV biomarkers with left ventricular hypertrophy (LVH). METHODS: A panel of five CV biomarkers (asymmetric dimethyl arginine, high sensitivity C-reactive protein, homocysteine, N-terminal pro-B type natriuretic peptide and uric acid) were measured on the same day as an echocardiogram assessment, in paediatric patients with pre-dialysis stages 3-5 of CKD. RESULTS: Of 73 children aged 5-18 years, LVH, all eccentric, was identified in 38%. Systolic blood pressure (BP), glomerular filtration rate (GFR) and higher intake of calcium-based phosphate binders were significantly worse in children with LVH. In multivariate models analysing each biomarker one at a time with confounders [GFR, systolic BP z-score, anti-hypertensive medication (yes/no) and elemental calcium intake], clinic systolic BP z-score and elemental calcium intake consistently displayed a significant relationship with indexed left ventricular mass (LVMI). None of the evaluated CV biomarkers displayed a significant relationship with LVMI. CONCLUSIONS: In our cohort of children with moderately severe pre-dialysis CKD we have identified no suitable biomarkers to detect LVH. We would therefore recommend that echocardiographic determination of LVMI remains the technique of choice for detection of LVH in children with CKD.

Home Doppler blood pressure monitoring in infants and children: a pilot study of its feasibility and clinical utility.

BACKGROUND: Out-of-hospital measurements of blood pressure (BP) are important for investigating and managing hypertension, but information is limited regarding the right technique to use in infants, small children and those intolerant of ambulatory BP monitoring. The aim of the study was to determine the feasibility and clinical utility of home Doppler BP monitoring (HDBPM). METHODS: This single-centre study included all consecutive patients referred to a tertiary hypertension clinic who underwent HDBPM over a 12-month period. Parents were taught to measure systolic BP using a Doppler instrument. RESULTS: HDBPM was successfully performed in 15 children (median (IQR) age 2.2 (0.9-3.7) years). All six patients referred for confirmation of newly diagnosed hypertension following sustained elevated clinic BP levels were found to be normotensive. Of the nine children referred with 'treated hypertension' for monitoring currently elevated clinic BP levels, four had confirmed hypertension and five were normotensive on HDBPM. In all nine 'treated hypertensive' patients, medication changes and normotensive BP levels were achieved with on-going home Doppler monitoring. 11/15 (73.3%) subjects successfully performed ≥1 BP measurement on at least 24 days of the 28-day monitoring period. The median (IQR) number of BP measurements performed weekly through week 4 of HDBPM were 22 (13-36), 18 (12-38), 18 (11-36) and 16 (8-32) respectively. No patient was hospitalised for further BP monitoring. CONCLUSIONS: HDBPM is acceptable to children and their families, demonstrating its feasibility as an out-of-office measurement technique. The initial results and the reliability of HDBPM need to be explored in larger clinical studies.

Collapsing glomerulopathy in a girl with systemic lupus erythematosus.

Collapsing glomerulopathy has increasingly been recognised in patients with conditions other than HIV. The non-HIV form of collapsing glomerulopathy generally shows little response to standard therapies. We describe a 12-year-old girl with a pre-existing diagnosis of systemic lupus erythematosus presenting with renal failure. A renal biopsy gave the histological diagnosis of collapsing glomerulopathy with evidence of "full-house" immunostaining. We propose collapsing glomerulopathy in her case, as no other cause was found was secondary to systemic lupus erythematosus. The immunophenotype of her podocytes suggested a partial de-differentiation that might have been important in her partial response to immunosuppression.