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BACKGROUND: The overall cost of managing chronic diseases is a significant barrier to accessing complete and timely healthcare, especially in rural and geographically isolated areas. This cost disparity becomes more pronounced in the case of children and more so in under-resourced regions of the world. In the era of COVID-19, as the need for physical distancing increased, there was a transition in approach to healthcare provision to telemedicine consultations. This study evaluates the cost saving using teleconsultations in a paediatric nephrology clinic. METHODS: This prospective cohort study was conducted at AIIMS Jodhpur, a tertiary care centre in western Rajasthan from March 2021 to October 2022. All consecutive paediatric (29 days-18 years) patients attending telemedicine services for kidney-related illness were enrolled. Basic demographic details were collected. Cost analysis was done after 6 months, regarding perceived cost savings for the patient and family by using telehealth for follow-up during 6 months starting from enrolment. RESULTS: A total of 112 patients were enrolled; 266 teleconsultations attended; 109 patients who could be followed up saved INR 457,900 during 6 months of follow-up. The average cost saving was INR - 1577/patient/visit. Patients saved 4.99% of the family income (median 2.16% (IQR 0.66-5.5)). The highest expenditure per visit was incurred for food and transport. The median distance from the residence to the clinic was 122.5 km (IQR 30-250). Over the 6-month study period, patients saved a travel distance of 83,274 km (743 km/patient). CONCLUSIONS: The use of telemedicine as a follow-up method helps save significant costs and distances travelled by patients. A higher-resolution version of the Graphical abstract is available as Supplementary information.
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Nefrologia , Telemedicina , Criança , Humanos , Redução de Custos , Custos e Análise de Custo , Países em Desenvolvimento , Índia , Estudos Prospectivos , Telemedicina/métodos , Lactente , Pré-Escolar , AdolescenteRESUMO
Digital gangrene is a rare presenting feature of childhood lupus and only a reported incidence of 1.3%. We describe two cases of pediatric onset systemic lupus erythematosus (SLE), both 16 years old, presenting with digital gangrene and the successful salvage of the digits after using intravenous cyclophosphamide for immunosuppression and use of intravenous prostaglandin E1 infusions for limb reperfusion. Both of the patients responded exceptionally to the infusions with resolution of gangrene and near-total preservation of the functionality of toes.
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Lúpus Eritematoso Sistêmico , Humanos , Criança , Adolescente , Lúpus Eritematoso Sistêmico/complicações , Lúpus Eritematoso Sistêmico/tratamento farmacológico , Gangrena/etiologia , Prostaglandinas , Dedos , Dedos do Pé , Ciclofosfamida/efeitos adversosRESUMO
BACKGROUND: One-third of children with type 1 diabetes mellitus manifest with diabetic ketoacidosis (DKA). Most children presenting with DKA are in a volume-depleted state, leading to acute kidney injury (AKI). Besides volume depletion, hyperglycemia can induce tubular injury and kidney inflammation. Therefore, a thorough knowledge of incidence of AKI, risk factors, and outcomes in pediatric DKA is desirable to improve its management and outcomes. OBJECTIVE: To synthesize currently available evidence on the incidence, risk factors, and outcomes of AKI in children with DKA. DATA SOURCES: We searched three electronic databases (EMBASE, PubMed, and Web of Science) from inception to September 2022 for original studies reporting AKI in children with DKA. Search strategies for the individual databases were drafted using free text words and MeSH incorporating "acute kidney injury" and "diabetic ketoacidosis." STUDY ELIGIBILITY CRITERIA: Cohort and cross-sectional studies reporting AKI in children with type 1 DM and DKA were included. PARTICIPANTS AND INTERVENTIONS: Children (aged less than 18 years) with type 1 DM and DKA. STUDY APPRAISAL AND SYNTHESIS METHODS: The critical appraisal tool of NHLBI for cohort studies was used to assess the quality of the studies. We estimated the pooled incidence of AKI with 95% CI in children with DKA using a random effects model. The primary outcome was the pooled incidence of AKI during the DKA episodes. RESULTS: Twenty-one studies assessing 4087 children (4500 DKA episodes) reported AKI during DKA episodes. The pooled incidence of any stage of AKI during the DKA episode was 47% (95% CI: 40 to 55). Severe AKI was observed in 28% (21 to 35) of DKA episodes; however, only 4% (1 to 11%) of children with AKI received dialysis. Low serum bicarbonate, low corrected sodium, higher blood sugar, and high blood urea nitrogen at presentation have been reported to be associated with the development of AKI. CONCLUSION: AKI developed in almost half of the DKA episodes, and every fourth DKA episode was associated with severe AKI. The recovery rate from DKA-associated AKI appears to be high; however, further studies are needed to assess the exact impact of AKI on long-term outcomes. REGISTRATION: PROSPERO (CRD42022303200). A higher resolution version of the Graphical abstract is available as Supplementary information.
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Injúria Renal Aguda , Diabetes Mellitus Tipo 1 , Cetoacidose Diabética , Hiperglicemia , Humanos , Criança , Cetoacidose Diabética/complicações , Cetoacidose Diabética/epidemiologia , Cetoacidose Diabética/terapia , Incidência , Estudos Transversais , Diálise Renal/efeitos adversos , Diabetes Mellitus Tipo 1/complicações , Diabetes Mellitus Tipo 1/epidemiologia , Injúria Renal Aguda/etiologia , Injúria Renal Aguda/complicações , Rim , Estudos RetrospectivosRESUMO
Acute kidney injury (AKI) in children with Transposition of Great arteries (TGA) undergoing Arterial Switch operation (ASO) is an important complication in the post-operative period associated with worse outcomes. AKI in children post open cardiac surgery has been well studied, with lesser data in literature pertaining to TGA and its sub-types specifically. This was a prospective, observational study enrolling infants with TGA undergoing ASO at a single center over a span of a decade from January 2010 to December 2020. The infants were followed during the duration of ICU and hospital stay, with documentation of baseline and intraoperative parameters as well as post-operative course. Out of 145 infants enrolled in the study, 83.1% developed AKI with majority (83.9%) having stage 1 AKI. Higher odds of AKI were seen in infants requiring Norepinephrine [odds ratio - 16.76 (95% CI 2.19-128.2), p < 0.001] and those who developed gram-negative infections [2.81 (1.04-7.56), p - 0.036]. Infants with AKI had significantly higher vasoactive-inotropic support at day 1 than those without AKI [16 (12.5-21.50 vs 13 (10.25-15.75), p - 0.014]. Seventeen infants in the AKI group (14%) died as opposed to none in the non-AKI group (p = 0.076). Median hours of ventilator support required were significantly higher in those with AKI than those who did not develop AKI (48 vs 45.5 p = 0.015). The infants with ASO + ASD + PDA (53% of neonates who died) were younger, had less weight at admission, more gram-negative sepsis and need for dopamine, as compared to ASO + VSD + ASD (23.5% of mortality) and ASO + ASD + VSD + aortic arch repair (23.5% of mortality). AKI in infants with TGA undergoing ASO is common and associated with poorer outcomes. In this subpopulation, AKI development is associated most commonly with hemodynamic instability and infections. This is the first study, looking at outcomes of TGA depending on the sub-types of ASO surgeries done in the infants [ASO with ASD + PDA or ASD + VSD or ASD + VSD + Arch Repair].
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Injúria Renal Aguda , Transposição das Grandes Artérias , Transposição dos Grandes Vasos , Lactente , Recém-Nascido , Criança , Humanos , Transposição das Grandes Artérias/efeitos adversos , Estudos Prospectivos , Dopamina , Transposição dos Grandes Vasos/cirurgia , Injúria Renal Aguda/epidemiologia , Injúria Renal Aguda/etiologia , NorepinefrinaRESUMO
The incidence of thrombotic microangiopathy (TMA) following snake bite is reported to be ranging from 3.6 to 15%. We report a 10-year-old boy who developed TMA and due to venom-induced consumptive coagulopathy (VICC) despite receiving adequate and timely doses of snake antivenom following a bite of saw-scaled viper (Echis carinatus sochureki). VICC was managed by plasmapheresis. Though snake bite envenomation-associated renal complications are not uncommon, possibility of TMA should be considered early during management. Our patient developed TMA with subsequent acute cortical necrosis after saw-scaled viper bite despite an adequate and timely dose of snake antivenom which emphasizes the ineffectiveness of antivenom against the venom of given snake species leading to long-term complications.
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Mordeduras de Serpentes , Microangiopatias Trombóticas , Viperidae , Animais , Humanos , Antivenenos/uso terapêutico , Mordeduras de Serpentes/complicações , Mordeduras de Serpentes/terapia , Venenos de Víboras , Microangiopatias Trombóticas/induzido quimicamente , Microangiopatias Trombóticas/terapiaRESUMO
OBJECTIVES: The decision to surgically intervene in a hydronephrotic kidney in children is based on many debatable guidelines, some requiring repeated ultrasounds or renal scans. Urinary proteins have the potential to reflect renal disorders and hence can be the alternatives to such scans. Here, we aim to assess the role of urinary Neutrophil Gelatinase-Associated Lipocalin, Monocyte Chemoattractant Protein-1, and Interleukin-6 (IL-6) in such patients. METHODS: Seventeen children had obstructive hydronephrosis requiring pyeloplasty (UPJO), while seven were kept on conservative management in view of non-obstructive dilation (NOD). Urine samples were measured for the three urinary proteins at the time of presentation and following pyeloplasty using commercially available ELISA kits. RESULTS: The levels of all three urinary proteins were significantly higher in patients with UPJO children compared to the NOD group. Cut-off values to differentiate obstructive from non-obstructive hydronephrosis were obtained. A significant fall in the post-operative value of urinary IL-6 was also observed. CONCLUSION: This study highlights the potentiality of urinary proteins as biomarkers in identifying children with hydronephrosis and picking out the ones with obstructive hydronephrosis who will require pyeloplasty. The drop in levels after pyeloplasty can be employed to evaluate the effectiveness of pyeloplasty when sent serially.
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Quimiocina CCL2/urina , Hidronefrose , Interleucina-6/urina , Lipocalina-2/urina , Biomarcadores/urina , Criança , Humanos , Hidronefrose/diagnóstico , Hidronefrose/cirurgiaRESUMO
AIM: To determine the clinicopathological characteristics and outcomes of children diagnosed with lupus nephritis in a tertiary hospital in western Rajasthan and compare it with the data available from other parts of India. MATERIAL AND METHODS: A retrospective review of children presenting to a tertiary care center in western Rajasthan, India, with a diagnosis of pediatric Systemic Lupus Erythematosus (p SLE), between July 2017 and July 2020 was done. Comparisons of pediatric lupus in western India to other parts of country were done. RESULTS: 19 children with SLE with Renal involvement were enrolled and followed up. The median age at presentation was 15 years (IQR-16-9.5) (73% females). 8/19 (42%) children presented with AKI, of which 62% children presented as rapidly progressive renal failure. Six (37.5%) patients required dialysis at presentation. 84.21% of children were evaluated with renal biopsy, 16 biopsies were done in 19 children, among which class II, III, and IV lupus nephritis were reported in 21%,42%, and 35% respectively(4 crescentic). Antiphospholipid antibodies were positive in 8/15(53%), children which is much higher than a reported incidence of 30% in other Indian studies. Ten patients (52%) had neurological involvement, with seizures being the most common form of presentation (60%). Seven patients (36%) developed hepatitis. We noted many uncommon presentations in the small group like Autoimmune Pancreatitis, Mononeuritis multiplex, and peripheral digital gangrene. Cyclophosphamide was used in 10 out of 19 patients for inducing remission with class 3 and 4 nephritis and MMF in 8 children. 55% patients attained remission (after completing induction), of which 4 relapsed during the follow up. Four patients were lost to follow-up. A total of 27% patients died and 10% patients developed end stage renal failure. It was seen that those who died had more cardiac and neurological involvement at presentation, higher grade of proteinuria, lower GFR, and need for dialysis at admission. CONCLUSION: We found a more severe form of clinical manifestation in pediatric SLE patients at the time of the first presentation in the form of severe renal and extrarenal manifestation compared to other parts of the country.
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Lúpus Eritematoso Sistêmico/epidemiologia , Nefrite Lúpica/epidemiologia , Adolescente , Criança , Ciclofosfamida/uso terapêutico , Feminino , Humanos , Índia/epidemiologia , Lúpus Eritematoso Sistêmico/tratamento farmacológico , Nefrite Lúpica/diagnóstico , Nefrite Lúpica/tratamento farmacológico , Masculino , Estudos RetrospectivosRESUMO
BACKGROUND: Accurate and detailed measurements of spinal canal diameter (SCD) and transverse foraminal morphometry are essential for understanding spinal column-related diseases and for surgical planning, especially for transpedicular screw fixation. This is especially because lateral cervical radiographs do not provide accurate measurements. AIM:: This study was conducted to measure the dimensions of the transverse foramen sagittal and transverse diameters (SFD, TFD), SCD, and the distance of spinal canal from the transverse foramina (dSC-TF) at C1-C7 level in the Indian population. MATERIALS AND METHODS:: The study population comprised 84 male and 42 female subjects. The mean age of the study group was 44.63 years (range, 19-81 years). A retrospective study was conducted, and data were collected and analyzed for patients who underwent cervical spine computed tomography (CT) imaging for various reasons. RESULTS: One hundred and twenty-six patients were included in the study. Detailed readings were taken at all levels from C1-C7 for SCD, SFD, TFD, and dSc-TF. Values for male and female subjects were separately calculated and compared. For both the groups, the widest SCD were measured at the C1 level and the narrowest SCD at the C4 level. The narrowest SFD was measured at C7 for both male and female subjects on the right and left sides. The widest SFD was measured at C1 both for male and female subjects on the right and left side. The narrowest TFD on the left side was measured at C7 for male and at C1 for female subjects. The narrowest mean distance of dSC-TF was found to be at C4 for both male and female subjects on both left and right side. CONCLUSION: The computed tomographic (CT) imaging is better than conventional radiographs for the preoperative evaluation of cervical spine and for better understanding cervical spine morphometry. Care must be taken during transpedicular screw fixation, especially in female subjects, more so at the C2, C4, and C6 levels due to a decrease in the distance of dSC-TF.
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Procedimentos Ortopédicos/métodos , Canal Medular/diagnóstico por imagem , Canal Medular/cirurgia , Doenças da Medula Espinal/diagnóstico por imagem , Doenças da Medula Espinal/cirurgia , Tomografia Computadorizada por Raios X , Adulto , Idoso , Idoso de 80 Anos ou mais , Parafusos Ósseos , Vértebras Cervicais/diagnóstico por imagem , Feminino , Forame Magno , Humanos , Índia , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosAssuntos
Hiperpotassemia/diagnóstico , Letargia/etiologia , Pneumonia/complicações , Potássio/sangue , Síndrome do Desconforto Respiratório do Recém-Nascido/diagnóstico , Consanguinidade , Diagnóstico Diferencial , Humanos , Hiperpotassemia/complicações , Hiperpotassemia/terapia , Recém-Nascido , Masculino , Diálise Peritoneal , Pneumonia/sangue , Pneumonia/terapia , Respiração Artificial , Síndrome do Desconforto Respiratório do Recém-Nascido/sangue , Síndrome do Desconforto Respiratório do Recém-Nascido/etiologia , Síndrome do Desconforto Respiratório do Recém-Nascido/terapia , Índice de Gravidade de DoençaAssuntos
Canais Epiteliais de Sódio/genética , Hiperpotassemia/diagnóstico , Letargia/etiologia , Potássio/sangue , Pseudo-Hipoaldosteronismo/diagnóstico , Injúria Renal Aguda/diagnóstico , Hiperplasia Suprarrenal Congênita/diagnóstico , Quelantes/administração & dosagem , Consanguinidade , Análise Mutacional de DNA , Diagnóstico Diferencial , Hidratação , Humanos , Hiperpotassemia/complicações , Hiperpotassemia/genética , Hiperpotassemia/terapia , Recém-Nascido , Masculino , Mutação , Diálise Peritoneal , Poliestirenos/administração & dosagem , Pseudo-Hipoaldosteronismo/sangue , Pseudo-Hipoaldosteronismo/complicações , Pseudo-Hipoaldosteronismo/genética , Sepse/diagnóstico , Índice de Gravidade de Doença , Sódio/administração & dosagemRESUMO
Supernumerary kidneys are a rare congenital anomaly with fewer than 100 cases reported over the years. A fused supernumerary kidney is a still rarer entity. We present imaging findings in two cases of supernumerary kidneys--the first case is a spectacular image of four kidneys in one patient seen in an excretory phase of intravenous urogram with only four cases described in the literature. The second case is that of three kidneys (fused supernumerary) seen in another patient.
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Rim/anormalidades , Meios de Contraste , Humanos , Rim/diagnóstico por imagem , Rim/patologia , Imageamento por Ressonância Magnética/métodos , Masculino , Intensificação de Imagem Radiográfica/métodos , Tomografia Computadorizada por Raios X/métodos , Urografia/métodosRESUMO
Primary hyperoxaluria-1 (PH1) is an autosomal recessively inherited rare genetic condition due to the deficiency of the hepatic enzyme alanine:glyoxylate aminotransferase which leads to high systemic levels of oxalate and subsequently, early end-stage renal disease and death. Here, we present a case of a three-month-old male infant who presented with loose stools, reduced oral intake, and decreased activity for 12-13 days along with edema and a peeling rash on cheeks, lips, and genitalia. During the entire duration of the inpatient stay, the child was oligoanuric. Kidney ultrasound (USG) was suggestive of bilateral hyperechoic kidneys with increased cortical echogenicity and a computed tomography scan showed bilateral diffusely calcified renal cortices with well-preserved renal architecture. A diagnosis of "oxalate nephropathy" was made from renal biopsy and genetic testing confirmed it to be "primary hyperoxaluria-1". The child was initially managed conservatively, and then peritoneal dialysis was done, following which the child was shifted to intermittent hemodialysis.
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Calcium gluconate solutions are an essential part of the intensive care medication armamentarium. Calcium-related extravasations are not an infrequent occurrence. However, occult extravasation presenting solely as an isolated mass lesion with no preceding cutaneous manifestation is rare. Calcinosis cutis is an extraosseous collection of calcium deposits in the skin and subcutaneous tissues. Multiple etiopathogenetic factors play a role in its manifestations. We illustrate a case of a seven-week-old infant diagnosed with pseudo-hypoaldosteronism with a mysterious swelling on the left leg during the third week of hospitalization, which was attributed to occult iatrogenic calcinosis cutis.
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Giardiasis is an infection of the small intestine caused by the protozoan parasite Giardia intestinalis and one of the most common parasitic intestinal diseases in humans worldwide. It mainly manifests as a self-limited illness in the case of immunocompetent patients and usually does not require treatment. However, immunodeficiency is a risk factor for the onset of severe Giardia infection. In this report, a case of recurrent giardiasis refractory to nitroimidazole therapy is presented. A 7-year-old male patient with steroid-resistant nephrotic syndrome came to our hospital because of chronic diarrhoea. The patient was on long-term immunosuppressive therapy. Microscopic examination of stool showed a significant number of trophozoites and cysts of G. intestinalis. Treatment with metronidazole for longer duration than recommended has failed to clear the parasite in the present case.
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Acute kidney injury (AKI) is an important factor affecting the outcome of hospitalized patients under any disease condition. While a lot has been said and studied about pulmonary manifestations of COVID-19 and multisystem inflammatory syndrome in children, this review focuses on its renal manifestations in children with and its complications. For the collection of data, the patient intervention control outcome model was applied to determine all eligible studies. The data was extracted using PubMed/Medline, Embase, and Google Scholar databases using a combination of keywords (AKI, renal failure, kidney disease, children, pediatric, covid-19, SARS COv2). Studies were reviewed after the exclusion of duplicates. The incidence of renal involvement in COVID 19 is up to 10-15%, which is higher than SARS. Both direct and indirect pathogenic mechanisms operate in patients with COVID 19 leading to varied manifestations. While AKI remains the most common manifestation in children admitted to intensive care units, other manifestations like, proteinuria, hematuria, rhabdomyolysis, and thrombotic microangiopathy have also been described in the literature. The children already on immunosuppression due to transplant or immune-mediated renal disorders do not seem to have more severe illness than those without it. The principles of management of AKI in COVID have not been different than other patient groups.
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Background and aims: Early detection and management of renal abnormalities in children can reduce the progression of paediatric chronic kidney disease. Currently, data on the prevalence of routine abnormal urinary parameters are scarce in Indian population. This study aims to identify the prevalence of asymptomatic kidney diseases in Indian school children and the population who may benefit from routine urinary screening tests for timely identification and intervention of asymptomatic renal diseases. Materials and methods: A total of 1675 children from a North Indian, multiethnic population aged 5-19 years were screened for hematuria and proteinuria by dipstick test from a midstream, clean urine specimen. The children who tested positive had their urine tested further for microscopy. The incidences of proteinuria and hematuria were also separately checked in hypertensive children. Results: 76 children had urinary abnormalities with the prevalence of isolated haematuria in 1.9%, isolated proteinuria in 0.35% and glycosuria in 0.06%. When these children were followed with urine microscopy, 44 were observed to have abnormal findings. Of these, 4.5% children had proteinuria, 34% had isolated hematuria, and 47.7% had isolated WBCs. The prevalence for proteinuria was 0.60% and the prevalence for hematuria was 2.99% (in upper decile of SBP) in hypertensive children, both of which were more than the prevalence in otherwise healthy children. Conclusion: Urine screening is a non-invasive, inexpensive test for early detection of occult renal diseases. A large-scale study with follow-up of children with urinary abnormalities will further establish the benefit, if any, of a national paediatric urine screening programme.
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[This corrects the article DOI: 10.3389/fped.2021.833205.].