Posterior urethral valve in thai boys.

BACKGROUND: Posterior urethral valve (PUV) is the most common congenital bladder outlet obstruction in boys, causing renal damage beginning in utero. There are scarce data from Thailand regarding the long-term outcomes of PUV in boys, thus the aim of this study was to examine the presentation, clinical course, complications, outcomes and renal survival in PUV boys. METHODS: We reviewed the medical records of PUV boys treated at the Pediatric Nephrology Clinic, Prince of Songkla University, Thailand, over a 30-year-period. RESULTS: Seventy-seven PUV boys were identified, with a median age at diagnosis of 4.8 months. The most common presentations were urinary tract infection (UTI), poor urine stream and urinary dribbling in 26 (33.8%), 19 (24.7%) and 11 (14.3%) boys, respectively. Renal ultrasound results in 70 boys showed 8 (11.4%) unilateral and 56 (80%) bilateral hydronephroses. Of 72 voiding cystourethrograms, 18 (25.0%) showed unilateral and 22 (30.6%) bilateral vesicoureteral refluxes. 99mTc dimercaptosuccinic acid renal scans in 30 boys showed 12 (40%) unilateral and 8 (26.7%) bilateral renal damage. Fifty-nine (76.6%) boys had 149 UTIs; 42 (54.4%) had recurrent UTI. Forty-eight boys had valve ablation at the median age of 30.3 months. 22 boys (28.6%) developed chronic kidney disease (CKD) at a median age of 15.0 years. CONCLUSION: Of 77 PUV Thai boys, UTI was the most common presentation. Recurrence of UTI and CKD was the most common consequence. Lifelong follow-up for renal and bladder functions is essential for all PUV patients.

Acute kidney injury and childhood acute myeloid leukemia.

BACKGROUND: Acute kidney injury (AKI) appears to be particularly common in children with acute myeloid leukemia (AML), although the epidemiology data on this patient population is sparse. The objective of this study was to assess the prevalence and factors associated with AKI in childhood AML during chemotherapy treatment. METHODS: The medical records of 112 children aged under 15 years diagnosed with AML who received chemotherapy in a major tertiary-care referral center in southern Thailand were reviewed. Logistic regression was used to identify factors associated with AKI. RESULTS: Fifty-six (50%) children had AKI events. The median time from AML diagnosis to the first AKI was 29.5 days (interquartile range: 11.0-92.8) and the median follow-up time was 10.9 months (interquartile range: 3.6-31.1). Age at diagnosis ≥ 10 years (OR 2.75, 95% CI 1.09-6.93), glomerular filtration rate < 90 mL/min/1.73 m2 at AML diagnosis (OR 7.58, 95% CI 1.89-30.5), and septic shock (OR 22.0, 95% CI 4.63-104.3) were independently associated with AKI. CONCLUSIONS: Childhood AML has a high rate of kidney injury with 50% having AKI. Age ≥ 10 years at diagnosis, impaired kidney function before treatment, and septic shock were strongly associated with AKI. A higher resolution version of the Graphical abstract is available as Supplementary information.

Childhood-onset systemic lupus erythematosus and immune thrombocytopenia: Prevalence and risk factors.

BACKGROUND: There are few studies examining the prevalence and clinical risk factors for subsequent systemic lupus erythematosus (SLE) development after long-term follow-up in childhood immune thrombocytopenia (ITP). The aims of this study were to evaluate the prevalence and risk factors for subsequent SLE development in childhood ITP. METHODS: The medical records of childhood ITP patients aged under 15 years in a major tertiary care center in Southern Thailand were retrospectively reviewed. The Kaplan-Meier method was used to estimate the cumulative probability of subsequent SLE development after ITP. Logistic regression analysis was used to identify independent risk factors for SLE development. RESULTS: A total of 473 childhood ITP cases were included in the study. During a mean follow-up time of 6.1 ± 6.7 years, the prevalence of subsequent SLE development was 2.96%. Older age at ITP diagnosis (odds ratio [OR]: 1.24, 95% CI: 1.07-1.45) and chronic ITP (OR: 24.67, 95% CI: 3.14-100.0) were independent risk factors. The cumulative probabilities of subsequently developing SLE at 5 and 10 years after diagnosis of ITP were 3.8% (95% CI: 1.4-6.2) and 6.5% (95% CI: 2.9-9.8), respectively. CONCLUSION: Older age at ITP diagnosis and chronic ITP were risk factors for subsequent SLE developed in childhood ITP.

A 30-year retrospective study on causes of death in childhood-onset systemic lupus erythematosus in a tertiary care centre in Southern Thailand.

OBJECTIVES: We set out to determine the causes of death in childhood-onset systemic lupus erythematosus (cSLE). METHODS: The medical records of children aged <18 years who were diagnosed with SLE from 1985 to 2016 in the Division of Nephrology, Department of Paediatrics, Faculty of Medicine, Prince of Songkla University, Thailand, were reviewed. RESULTS: There was a total of 331 patients, 272 girls and 59 boys, of whom 77 (23.3%) died, 28.6% within the first year after diagnosis. Only 29 medical records of the 77 confirmed-death patients were available for evaluation of cause of death; 7 boys and 22 girls, with a mean age at presentation of 10.9±3.1 years. The mean follow-up duration was 4.6±3.7 (range 0.2-12.6) years. The major cause of death was sepsis (n=13 patients with 15 identified organisms, which were Acinetobacter baumannii (9), Escherichia coli (3), Candida albicans (2) and Aspergillosis (1)), followed by acute respiratory distress syndrome (ARDS) (6), severe heart condition (3), acute kidney injury (AKI) (2), chronic kidney disease (CKD) (2) and intracranial haemorrhage (1). Conditions at the time of death were sepsis (25), pneumonia (16), AKI (15), bleeding disorders (11), neurological complications (10), ARDS (10), CKD (4), AKI in addition to CKD (3). CONCLUSIONS: The cause of death in cSLE is usually multi-factorial and it is difficult to assign a single dominant cause. Sepsis was the most common cause of death and, together with sepsis-related organ failure, was the most common condition at the time of death. The most common organism was Acinetobacter baumannii.

Characteristics and Findings of Childhood Urinary Tract Infection in the Last Decade.

BACKGROUND: The strong association between kidney and urinary tract anomalies and childhood urinary tract infection (UTI) often leads to imaging tests being performed. -Objective: To describe the epidemiology, characteristics, and imaging findings in Thai children with UTI and compare results between boys and girls. METHODS: We retrospectively reviewed the medical records of children with UTI aged < 15 years. Demographic characteristics and findings of investigations are presented. RESULTS: One hundred seventy-eight boys and 170 girls with 432 UTI episodes were identified. The median (interquartile range) age at presentation was 1.4 (0.6-3.4) years, 1.0 for boys and 2.1 for girls (p < 0.001). Renal ultrasound, voiding cystourethrogram and 99mTc dimercaptosuccinic acid (DMSA) renal scans were performed in 273, 223 and 113 children, respectively. Overall, 283 children (81.3%) had at least one imaging study done and anomalies of the kidney and urinary tract were detected in 158 (45.4%). Primary vesicoureteral reflux was detected in 73 (32.7%) children. The remaining abnormalities were hydronephrosis (n = 54). DMSA scans detected 54 children with dysplastic or scarred kidneys. CONCLUSIONS: First UTI in a group of Thai children occurred in approximately equal proportion in boys and girls but boys were younger at diagnosis. Kidney and urinary tract anomalies were detected in half of the children.

Improvement of survival rates in the last decade in Thai childhood-onset systemic lupus erythematosus.

BACKGROUND: Morbidity and mortality in childhood onset systemic lupus erythematosus (SLE) is more severe than adult onset SLE. Long-term follow up is needed to determine the prognosis. The objectives of this study are to describe the mortality of childhood SLE in a single tertiary care centre over three decades, compare trends in survival over time, and determine predictors for survival. METHODS: We retrospectively reviewed the medical records of children aged < 18 years who were diagnosed with SLE at the Department of Pediatrics, Songklanagarind Hospital, Thailand, from 1985 to 2016. RESULTS: There were 331 children (272 girls, 59 boys) with a mean age at presentation of 11.5 ± 2.6 years. The mean follow-up duration was 7.0 ± 5.0 (range 1-28) years, 77 children (23.3%) died, 28.6% within the first year after diagnosis. The overall mortality rate was 3.3 per 100 person-years. Survival rates at 1, 5 and 10 years were 93.4%, 83.1% and 72.6%, respectively. Ten-year survival rates for the children diagnosed in the decades 1985-1996, 1997-2006 and 2007-2016 were 67.4%, 63.4% and 82.8%, respectively (p < 0.001). Boys had worse survival than girls (hazard ratio = 2.3, 95% CI: 1.4-3.7) even after adjusting for decade of diagnosis. Lupus nephritis (LN) class IV had similar survival compared to LN classes II/III/V combined (hazard ratio = 1.0, 95% CI: 0.6-1.7). CONCLUSION: In our setting, the survival rate of childhood onset SLE has improved during the past 10 years, but mortality is still high compared to developed countries, particularly in boys.

What Did We Find From Imaging Studies in Childhood Urinary Tract Infection and Which Studies Are Mandatory?

OBJECTIVE: To evaluate the imaging results of childhood urinary tract infection (UTI) in our setting, and examine if it would be appropriate to apply the recent guideline changes regarding imaging studies as routine practice in Thailand. METHODS: Medical records of children with UTI aged 0-15 years were reviewed, with focus on renal ultrasound (RUS), cystogram, and 99mTc dimercaptosuccinic acid (DMSA) renal scan results to determine congenital anomalies of the kidney and urinary tract (CAKUT) and renal damage. Mild CAKUT was defined as primary vesicoureteral reflux grades I-III or isolated hydronephrosis, and all other abnormalities were defined as severe CAKUT. RESULTS: A total of 142 boys and 129 girls had at least 1 imaging study after UTI. Their median (interquartile range) age was 1.0 (0.5-2.7) year: 0.7 and 1.4 years for boys and girls, respectively (P = .006). A total of 262 children had an RUS performed, of which 99 (37.8%) were abnormal. Cystograms were performed in 221 children, from which 83 (37.6%) CAKUTs were detected, and 108 children had a DMSA performed, of which 53 (49.1%) were abnormal. Overall, CAKUTs were detected in 148 (54.6%) children, of which 43 were severe. RUS together with cystogram provided higher sensitivity (100% vs 88.9%) and specificity (53.8% vs 42.4%) to detect severe CAKUT than RUS together with DMSA. CONCLUSION: A CAKUT was detected in more than half of the children with first UTI, with one-third having severe CAKUT. In our setting, RUS combined with cystogram is still the most reliable way to detect potentially harmful post-UTI problems, and the new western guidelines are not appropriate.

Primary vesicoureteral reflux: A 26-year experience in a single centre.

AIM: To determine the nature of primary vesicoureteral reflux (VUR) and the association of VUR with hydronephrosis and renal damage. METHODS: The medical records of children ≤ 15 years diagnosed with VUR, attending the Department of Pediatrics, Prince of Songkla University, Thailand between 1987 and 2013 were reviewed. Renal ultrasound and technetium-99m dimercaptosuccinic acid renal scan (DMSA) results were examined to determine the severity of hydronephrosis and renal damage, respectively. RESULTS: There were 177 boys and 211 girls. 350 (90.2%) were diagnosed following urinary tract infection (UTI). The median (IQR) age at diagnosis of first VUR was 7.6 (4.3-12.2) months in boys and 18.6 (9.0-46.6) months in girls (P < 0.001). Renal ultrasound was performed in 340 patients. Hydronephrosis was found in 105 patients and 135 kidneys and 22.5% VUR kidneys and 11.0% non-VUR kidneys (P = 0.01). The severity of hydronephrosis was associated with VUR grade (44.2% of grades IV and V VUR had hydronephrosis vs 11.9% of grades I-III VUR, P < 0.001). DMSA was performed in 332 patients. Abnormalities were found in 30.1% VUR kidneys and 4.1% non-VUR kidneys (P < 0.001). Abnormal DMSA results were strongly associated with VUR grade (17.8% for VUR grades I-III vs 60.5% for VUR grades IV and V, P < 0.001). CONCLUSION: Primary VUR in this group was most commonly diagnosed following investigation of UTI and detected during infancy, earlier in boys. Hydronephrosis and renal damage were associated with severity of VUR.

Dengue hemorrhagic fever and the kidney.

Dengue virus infection (DVI)/dengue hemorrhagic fever (DHF) is a common febrile illness with a variety of severities. The mortality rate is high in dengue shock syndrome (DSS), caused by circulatory failure due to plasma leakage resulting in multi-organ failure. However, acute kidney injury (AKI) is rarely reported. In areas of endemic DVI, the prevalence of AKI due to DVI has been reported to be as high as 6.0 % in children with AKI, and 0.9 % in children with DVI who were admitted to a hospital. The mechanism of AKI in DVI is not clear. It may result from (a) direct injury as in other infectious diseases, (b) an indirect mechanism such as via the immune system, since DHF is an immunological disease, or (c) hypotensive DSS, leading in turn to reduced renal blood supply and renal failure. The mortality rates of DF/DHF, DSS and DHF/DSS-related AKI are <1 %, 12-44 %, and >60 %, respectively. Kidney involvement is not actually that rare, but is under-recognized and often only reported when microscopic hematuria, proteinuria, electrolyte imbalance, or even AKI is found. The prevalence of proteinuria and hematuria has been reported as high as 70-80 % in DVI. A correct diagnosis depends on basic investigations of kidney function such as urinalysis, serum creatinine and electrolytes. Although DVI-related renal involvement is treated supportively, it is still important to make an early diagnosis to prevent AKI and its complications, and if AKI does occur, dialysis may be required. Fortunately, in patients who recover, kidney function usually completely recovers as well.

ELECTROLYTE DISTURBANCE AND KIDNEY DYSFUNCTION IN DENGUE VIRAL INFECTION.

Dengue virus infection (DVI) is endemic in tropical countries in both children and adults. The classical presentation includes fever, hepatomegaly, thrombocytopenia-related bleeding disorders, and plasma leakage. Multi-organ involvement, including kidneys is found in complex cases. Asymptomatic electrolyte disturbances, abnormal urinalysis, and more severe manifestation such as acute kidney injury (AKI) usually indicate kidney involvement. Such manifestations are not rare in DVI, but are often not recognized and can cause the physician to misread the real situation of the patient. The prevalence of electrolyte disturbances or kidney involvement reported in studies varies widely by country and mainly depends on the severity of DVI and age of the patients. The prevalence of DVI-induced AKI ranges from 0.2%-10.0% in children and 2.2%-35.7% in adults. The prevalence among all age groups appears to be increasing in the last decade. Dengue shock syndrome (DSS) has been reported to be an independent risk factor for AKI development. The mechanism of DVI-induced AKI is complex and the details are to date undetermined. Urinalysis, serum electrolytes and creatinine measurements should be performed to document renal involvement in DVI patients for early detection and initiation of appropriate fluid therapy with close monitoring. Renal replacement therapy may be required in some cases. The presence of AKI dramatically increases the mortality rate among both childhood and adulthood DVI from 12%-44% to more than 60%.

Tuberculosis in SLE patients: rare diagnosis, risky treatment.

We document three cases of tuberculosis (TB) in 237 systemic lupus erythematosus (SLE) patients. Their ages at SLE and TB diagnoses were 13/15, 10/25, and 13/24 years. All were female and in all the TB was diagnosed during a period of lupus flare-up when they were receiving prednisolone and other immunosuppressive drugs. All three patients had extrapulmonary TB: Two had miliary TB and one had disseminated TB through the muscles, left knee joint, and lungs. All three patients experienced anti-TB drug-induced hepatotoxicity manifesting as jaundice along with elevated transaminase enzymes from the first-line anti-TB drugs they received, leading to a change to second-line drugs in two of them. In conclusion, although TB in SLE patients is not common, it should be considered when a patient is nonresponsive to the SLE treatment. Higher rates of extrapulmonary TB and anti-TB drug-induced hepatotoxicity in SLE patients with TB were noted.

Systemic lupus erythematosus-related pancreatitis in children.

We report on three patients who developed four episodes of acute pancreatitis while their systemic lupus erythematosus was active and being treated with prednisolone. In all three, gastritis was first considered and treated due to abdominal pain, vomiting, and epigastric tenderness, but their symptoms did not improve. Then pancreatic enzymes were measured, which confirmed pancreatitis. Imaging studies showed an enlarged pancreas in one case, a normal pancreas in two cases, and a focal hypodense nonenhancing parenchyma in one case. Corticosteroids were prescribed for both active SLE and SLE-related pancreatitis. Pulse methylprednisolone was prescribed in one episode, increasing oral prednisolone in one episode, and the same dose of prednisolone continued in the other two episodes. All cases recovered without complications. SLE-related pancreatitis should be considered in SLE patients when the SLE is active and a patient develops abdominal pain and vomiting.

Intravenous cyclophosphamide combined with steroids in pediatric onset severe lupus nephritis.

BACKGROUND: Intravenous cyclophosphamide (IVCY) has been used to treat severe lupus nephritis (LN) for many years. Because of the wide variety of manifestations of the condition and the long-term nature of the disease, outcomes vary widely. OBJECTIVE: To evaluate and compare the immediate and long-term results of IVCY in pediatric onset severe LN and between patients with normal and abnormal initial renal function. METHODS: Patients aged <18 years who attended the Department of Pediatrics, Prince of Songkla University, diagnosed with severe LN, and who were given a 36-month IVCY course, were included. Comparison of overall survival between the two groups was assessed using Kaplan-Meier survival curves. RESULTS: 108 patients with a mean age of 12.6 ± 2.7 years were studied, with a mean follow-up time of 5.7 ± 4.3 years. 48 patients completed the IVCY course. 36 patients had abnormal renal function and 72 patients had normal renal function at the start of therapy. Both groups responded well initially to treatment; proteinuria reduced to normal levels after 1 and 2 treatments in the normal and abnormal groups, respectively, while creatinine clearance returned to normal levels after 8 treatments in the abnormal group. Overall survival was not different between the two groups; however, the abnormal renal function group had a higher crude mortality rate than the normal group (13/36 vs 10/72, p value = 0.02). At the time of analysis, some patients who had completed their IVCY course still required other therapy to control their disease activity. CONCLUSION: Three years of IVCY treatment provided similar outcomes in both normal and abnormal renal function groups. Immediate outcomes were favorable but long-term remission was not promising.

Childhood recurrent urinary tract infection in southern Thailand.

INTRODUCTION: Recurrent urinary tract infection (UTI) is one of the major health problems in children because of its high rate of occurrence. OBJECTIVE: Our aim of the study was to evaluate the prevalence and determine risk factors of recurrent UTI in Thai children. PATIENTS AND METHODS: The medical records of children aged less than 15 years diagnosed with UTI at the Department of Pediatrics, Songklanagarind Hospital were reviewed. RESULTS: A total of 307 children (144 boys, 163 girls) were followed up for at least 1 year. Fifty-six children, 31 (19.0%) boys and 25 (17.4%) girls, developed at least one recurrence totaling 153 recurrent UTI episodes. The recurrence rate was not statistically different between the sexes (p = 0.8). On multivariate analysis, genitourinary system (GU) anomalies, particularly vesicoureteral reflux (VUR), were the most significant risk factors. Children aged greater than 5 years had a slightly higher risk of recurrence, irrespective of gender. Comparison of organisms associated with recurrent UTI with those associated with first UTI showed that the prevalence of Escherichia coli decreased from 76.9% to 56.2% but was still the major causative agent. In contrast, the prevalence of Klebsiella pneumoniae and unusual or mixed organisms significantly increased from 7.8% to 15.0% and 6.2% to 16.3%, respectively. CONCLUSION: One-fifth of children who had UTI developed recurrence and the rates were similar for males and females. Independent risk factors for recurrent UTI were found to be at age of >5 years and underlying disease of either GU anomaly or VUR.

Neonatal acute kidney injury in a tertiary center in a developing country.

BACKGROUND: Acute kidney injury (AKI) is a common contributor to morbidity and mortality in newborns, with prevalences varying by population and hospital. A study of AKI in newborns in tertiary care centers in Thailand, a developing country with limited resources, has not been conducted yet. METHODS: The aim of this study was to determine the prevalence of AKI in newborns in a tertiary care hospital in southern Thailand and to investigate the etiology, mortality and risk factors of mortality. The records of patients aged <30 days with high serum creatinine, admitted from 1984 to 2007, were retrospectively reviewed. RESULTS: Eighty-eight boys and 51 girls were enrolled; 61.4% were premature and 56.5% had a birth weight <2500 g. The prevalence of newborn AKI increased from 0.9 to 6.3% during the 24-year study period. Thirty-nine and 65% had renal failure within 2 and 7 days post-birth, respectively. Sepsis was the most common cause of AKI (30.9%) followed by hypovolemia (18.7%), kidney, ureter and bladder (KUB) anomalies (12.2%), congestive heart failure (12.2%) and birth asphyxia (11.5%). Indomethacin caused AKI in 24.4% with gestational age <32 weeks. Sepsis-induced AKI had the highest mortality rate (65.1%) with an overall mortality rate of 38.8% and nearly 14 times the risk of death compared to hypovolemia-induced AKI. CONCLUSIONS: The prevalence of newborn AKI in our Thai tertiary center over 24 years was 6.3% of admitted newborns. Sepsis was the most common cause of AKI and sepsis-induced AKI is the most common cause of death. Disease etiology was the only risk factor for mortality.

Twenty-two years' experience with childhood-onset SLE in a developing country: are outcomes similar to developed countries?

INTRODUCTION: The outcome of systemic lupus erythematosus (SLE) has dramatically improved since the introduction of corticosteroids; however, although many regimens of treatment have been supplemented, the mortality has not improved further. OBJECTIVE: To describe the severity and outcome in patients diagnosed with SLE aged ≤18 years in a group of Thai children, compare gender and age differences, and our outcomes with those from developed countries. METHODS: The authors retrospectively reviewed the files of patients aged ≤18 years diagnosed with SLE admitted to Songklanagarind University Hospital in southern Thailand, for the period 1985-2007. Patient survival rates were calculated. RESULTS: There were 213 SLE patients, 41 males and 172 females, average age 11.6±2.6 years, with a median follow-up of 3.6 years. Outcomes were alive (109), lost to follow-up (22), referred (31) or deceased (51). Of the patients who were alive, 23 were not on any treatment, 59 were on prednisolone alone while 27 were on prednisolone plus some other immunosuppressive drug. Total survival rates were 88%, 76% and 64% at 2, 5 and 10 years, respectively. Males had significantly worse survival than females at 2 and 5 years (78% vs 91% and 58% vs 80%, respectively, p=0.018). There were no differences in mortality between age groups. The 5-year survival rates in the periods 1985-1993, 1994-2000 and 2001-2007 were not significantly different. CONCLUSION: This retrospective study of patients with SLE in southern Thailand showed different outcomes compared to some studies and similar survival rates and treatment status to other studies, with one-fourth of surviving patients being free of medication.

Outcome of dengue hemorrhagic fever-caused acute kidney injury in Thai children.

OBJECTIVES: To examine the outcome of acute kidney injury (AKI) in children with dengue hemorrhagic fever (DHF), the cause(s) of AKI, and the risk of AKI and fatality. STUDY DESIGN: The medical records of patients age <15 years during 1989 to 2007 were reviewed. DHF-caused AKI and patients with DHF with no AKI were matched 1:2 by age. RESULTS: DHF-caused AKI was clinically estimated to be 0.9% (25/2893) of admissions, with a high mortality rate of 64.0%. Risk factors of AKI were DHF grade IV and obesity (odds ratio, 16.9; 95% CI, 4.2 to 68.5, and odds ratio, 6.3; 95% CI, 1.4 to 28.8, respectively). Respiratory failure, hepatic failure, and massive bleeding were complications found in 80.0%, 96.0%, and 84.0% of cases with AKI, respectively. Fatality was more likely in cases with DHF grade IV, oliguric AKI, respiratory failure, or prolongation of prothrombin or activated partial thromboplastin time more than twice that of reference specimens. Among the survivors, none had chronic kidney disease, and serum creatinine levels returned to normal in 32 (1 to 48) days. CONCLUSIONS: Patients with DHF and AKI had a high mortality rate, although those who survived had a full return to normal function within 1 month. DHF grade IV and obesity were the major risk factors of AKI.

Is a repeat urine culture useful during antibiotic therapy for febrile urinary tract infection?

AIM: To evaluate the cost-effectiveness of a repeat urine culture after a few days of antibiotic therapy in childhood urinary tract infection (UTI) in southern Thailand. METHODS: A retrospective review of the medical record of children diagnosed with UTI aged less than 15 years in Songklanagarind Hospital from January 1995 to December 2004 was performed. Patient demographics were collected. The results of repeat urine culture after starting antibiotic were evaluated. The risk factors that indicated positive repeat urine culture were determined. RESULTS: Four hundred and forty-nine patients (245 boys and 204 girls) with 533 UTI episodes were analyzed, of which 49 (9.2%) had a repeat urine culture with significant growth. Multivariate analysis showed that age less than 1 year, aetiological agents Enterococci spp., fever of more than 72 h, inappropriate antibiotics and kidney, ureter and bladder anomalies were the most significant risk factors for a positive repeat culture, while sex, vesicoureteral reflux and recurrent UTI episodes were not significant risk factors. If the treatment protocol during the study period had indicated that children with at least one of the above risk factors should receive a repeat urine culture, then only 356 cases (66.8% +/- 2.0%) would have received a repeat test and $US 655 would have been saved, while five positive repeat urine cultures would have been missed. CONCLUSION: The present study in a group of Thai children indicates that a repeat urine culture during antibiotic therapy should still be recommended.

Severe hyperphosphatemia in a newborn with renal insufficiency because of an erroneous medical prescription.

We report on an 8-day-old boy with renal failure attributable to bilateral vesicoureteral reflux and dysplastic kidneys. He developed hyperphosphatemia because of his oral phosphate intake. Because he had mild metabolic acidosis, alkaline therapy was planned, but through a medical prescription error he was given a phosphate instead of an alkaline solution. He developed carpopedal spasm, with calcium and phosphate at 5.3mg/dL and 26.0mg/dL, respectively. His phosphate levels gradually decreased via diuretic and calcium gluconate therapy, without dialysis.

Diffuse proliferative glomerulonephritis does not determine the worst outcome in childhood-onset lupus nephritis: a 23-year experience in a single centre.

INTRODUCTION: Lupus nephritis (LN) is the major indicator of morbidity and mortality in systemic lupus erythematosus (SLE). Many studies have found a significantly worse patient survival rate in patients with LN class IV than patients with other LN classes. OBJECTIVE: The aim was to describe the severity and outcomes of LN in a group of Thai children. METHODS: We retrospectively reviewed the patient files of children diagnosed with SLE aged < or =18 years in Songklanagarind Hospital, Southern Thailand, from 1985 to 2007. RESULTS: Of 216 SLE patients, 180 had renal biopsy results, and the others were excluded from analysis. There were 33 males and 147 females, average age 11.8 +/- 2.6 years (range 3.6-18.0), with a median follow-up period of 3.9 years (range 9 days to 19.4 years). Using the WHO LN classification, there were 9, 55, 5, 94 and 14 patients of classes I-V, respectively, as well as 2 with end-stage renal disease and 1 with IgM nephropathy. The mortality rate was 23% (42/180). Patients with LN class II had a similar renal and patient survival compared to patients with LN class IV (P = 0.3 and 0.2, respectively). Cox proportional hazard regression analysis in 177 patients (3 patients who had a renal biopsy result outside the WHO classification were omitted) showed that gender was an independent risk factor for survival. Males had 2.6 times the hazard rate compared to females (95% CI 1.2-5.7, P = 0.03), but LN classification, age and timing of the renal biopsy were not significant. CONCLUSION: Renal and patient survival in LN classes II and IV were similar. Gender was the only independent risk factor of mortality, with males at greater risk than females.