A systematic review of interventions for reducing pain and distress in children undergoing voiding cystourethrography.

UNLABELLED: Voiding cystourethrography (VCUG) is commonly performed to screen for vesicoureteric reflux or other urological anomalies but has a potential to provoke distress in infants and children. We performed a systematic review of randomized controlled trials of interventions to reduce distress, pain or anxiety during VCUG. Eight trials (591 participants) met the inclusion criteria. CONCLUSION: Conscious sedation with midazolam effectively alleviates the distress of VCUG in children older than 1 year of age. Psychological preparation and warmed contrast medium may also be effective. Nitrous oxide 50% may be an alternative to midazolam, but further evidence is needed.

Waiting time and outcome of kidney transplantation in adolescents.

BACKGROUND: The major cause of late graft failure in adolescent kidney transplant recipients is thought to be nonadherence with medications. Delaying transplantation in adolescents may lead to improved adherence but at the cost of longer time on dialysis. To determine if waiting time on dialysis is a risk factor for graft survival in adolescents, we compared the outcomes of kidney transplants according to age and time on dialysis. METHODS: We analyzed data from the Australian and New Zealand Dialysis and Transplant Registry on 2,739 primary kidney transplants performed between 1980 and 2004 in recipients less than 30 years old. Outcomes according to age at transplantation and waiting time were analyzed by Kaplan-Meier curves, log-rank tests, and Cox proportional hazard tests. RESULTS: Overall five- and 10-year graft survival rates were significantly worse in adolescents (65% and 50%, respectively) compared to recipients aged two to 10 years (74% and 58%) and 20 to 29 years (72% and 57%). Waiting time on dialysis was an independent risk factor for failure of living donor grafts in adolescents (hazard ratio 0.53, P = 0.03). Five- and 10-year graft survival of preemptive grafts in adolescents were 82% and 70%, respectively, which were similar to survival rates of preemptive grafts in other age groups. CONCLUSIONS: Reduced graft survival rates in adolescent recipients are not seen after preemptive transplants. Preemptive grafts are associated with a 50% reduction in the risk of graft failure. Delaying transplantation in adolescents may expose them to increased risk of poorer outcomes.

The relative function of damaged kidneys in children does not deteriorate further at 3-year follow-up.

PURPOSE: It is thought that the function of a damaged kidney will deteriorate further with time because of impaired maturation and compensatory hyperfiltration. The aim of this study was to determine changes in relative renal function (RRF) over time in children with vesicoureteric reflux (VUR) and/or urinary tract infection (UTI) where the unilaterally scarred kidney was found to contribute 30% or less to overall function. PATIENTS AND METHODS: Children who met the inclusion criteria and had multiple radionuclide studies during a 12-year period were identified, and RRF was compared. RESULTS: Twenty-seven boys and 3 girls with a median age of 0.8 years (0.08-13.05 years) were included. Eight patients had unilateral VUR, 21 patients had bilateral VUR, and 1 patient had UTIs without VUR. Twenty-one patients underwent reimplantation surgery, and 9 were managed conservatively.At a mean follow-up of 2.64 years (0.26-6.77 years), there was a nonsignificant mean decrease in RRF from 19% (11%-28%) to 18% (9%-29%). The mean change in renal function was not affected by the severity of the initial RRF. CONCLUSIONS: In the medium term, there is no deterioration of RRF of unilaterally severely damaged kidneys associated with either VUR or UTI managed either surgically or conservatively. Boys are at a much greater risk of severe reflux nephropathy.

Renal length discrepancy by ultrasound is a reliable predictor of an abnormal DMSA scan in children.

A renal length discrepancy (RLD) of more than 10 mm by ultrasound (US) is accepted as a potential indicator of an underlying renal pathology; however, there are few supporting data for this in children. Our objective was to determine a cutoff at which RLD on US is a reliable predictor of dimercaptosuccinate acid (DMSA) scan abnormality. We present data from 90 patients who had both renal US and a DMSA scan, as well as DMSA scan results compared with bipolar RLD by US. Positive (PPV) and negative (NPV) predictive values were calculated for renal RLD from 6 to >10 mm. The left kidney was longer in 56%, whereas the right kidney was longer in 37%; their lengths were equal in 8%. For children at all ages, a left kidney longer than the right by >or=10 mm or a right kidney longer than the left by >or=7 mm gave a PPV for DMSA abnormality of 79% and 100%, respectively. In children older than 4 years, if the right kidney was longer by >or=7 mm or if the left kidney was longer by >or=10 mm, the PPVs for DMSA abnormality were 100% and 63%, respectively. In children younger than 4 years, when the right kidney was longer by >or=6 mm or the left was kidney longer by >or=10 mm, the PPV were 86% and 100%, respectively. Thus, children with a right kidney longer than the left by even <10 mm is a reliable predictor of an abnormal DMSA scan.

Post-streptococcal glomerulonephritis in Sydney: a 16-year retrospective review.

AIM: Post-streptococcal glomerulonephritis (PSGN) is a frequent cause of acute nephritis in children. Numerous studies have described PSGN in high-risk populations yet few data describing PSGN in a low-incidence population exist. This study aimed to describe the epidemiology, clinical manifestations, diagnosis, complications and outcomes of PSGN in an urban Australian population. METHODS: A 16-year retrospective review of case notes and laboratory data was conducted at a tertiary Sydney paediatric hospital. RESULTS: Thirty-seven children were treated for PSGN with a mean age of 8.1 years (range 2.6-14.1 years). Twenty-eight subjects (75.7%) had a history of a recent upper respiratory tract or skin infection. Hypertension and/or oedema was present in 29 subjects (78.4%). Streptococcal pharyngitis was identified as the likely source in 17 subjects (45.9%). Skin infections occurred less frequently. Antibodies against streptolysin O, streptokinase or deoxyribonuclease B were elevated when a single titre was measured in 35 subjects (94.6%). Thirty subjects (81.1%) developed renal impairment (median peak creatinine, 95 micromol/L, range 39-880 micromol/L). No correlation was demonstrated between peak creatinine, age, ethnicity, streptococcal titres and serum complement levels. The mean length of admission was 8.2 days. Seven subjects (18.9%) had a complicated course with three subjects requiring dialysis. Only one subject has ongoing renal dysfunction. CONCLUSION: Significant differences are seen in a low-incidence urban Australian population with PSGN when compared with endemic or epidemic disease in high-risk populations. The higher rates of complications that were seen compared with previously studied populations need further clarification.

Antibiotic-related renal failure and cystic fibrosis.

Recently published reports suggest that the combination of aminoglycosides with ceftazidime may increase the risk of renal disease in cystic fibrosis. We describe a case of unusually severe acute tubular necrosis occurring in an adolescent with cystic fibrosis receiving i.v. gentamicin plus ceftazidime and discuss the possible mechanisms.

Agreement on reporting of ambulatory blood pressure monitoring in children.

The use of ambulatory blood pressure monitoring (ABPM) can improve the accuracy of paediatric BP measurement and may better correlate with end-organ injury than office BP measurement. However, the interpretation of ABPM may be influenced by several variables. We sought to ascertain the agreement among three paediatric nephrologists when reporting 92 ABPM sessions performed on patients aged 5 to 18 years. All three nephrologists were in agreement on the presence or absence of hypertension in 64% of cases. They were less likely to concur about records where hypertension was borderline or if the ABP record contained fewer BP readings. These results highlight the need for evidence-based consensus regarding the interpretation of ABPM in children.

Retinoic acid may increase the risk of bone marrow transplant nephropathy.

Bone marrow transplant nephropathy (BMTN) classically presents more than 100 days after transplantation as an acute nephritis with hypertension, azotaemia and anemia that usually results in end stage renal failure (ESRF). The risk of developing BMTN may be greater with the use of more intensive chemotherapy and higher total body and tumor bed irradiation. Cis-retinoic acid (RA) may further increase the risk of developing BMTN. Here, we report the cases of two children who developed typical clinical and biochemical features of BMTN. They were both treated for stage IV neuroblastoma with chemotherapy, bone marrow transplant (BMT) conditioning that included total body irradiation and RA therapy after BMT, although the patient in case 1 had established renal insufficiency prior to the commencement of RA. Renal biopsy of these children showed classical BMTN histology, and the renal manifestations progressed quickly; the patient in case 1 became dialysis dependent by 1 year post-bone marrow transplant. Recently, RA has been added to the post-BMT therapy in children with stage IV neuroblastoma. The occurrence of BMTN in two children treated with RA in our unit is unlikely to be coincidental. Although RA has been shown to confer a significant survival advantage in this disease, animal studies and a previous case report have suggested it could increase the toxic effects of chemotherapy and renal irradiation. It is likely that RA contributed to the deterioration in renal function in these patients.

The relationship between serum creatinine, serum cystatin C and glomerular filtration rate in pediatric renal transplant recipients: a pilot study.

Serum cystatin C more accurately reflects glomerular filtration rate (GFR) in pediatric renal transplant recipients than serum creatinine. Nineteen pediatric renal transplant recipients, 15 male and 4 female, ranging in age from 8.35 yr to 19.06 yr (median 13.52 yr), were enrolled in the study over an 18-month period. Twenty-eight measurements of 99mTc-DTPA GFR were compared with simultaneous measurements of serum cystatin C and Cr. Linear regression analysis, Pearson correlation coefficients and analysis of variance (anova) were used to determine the relationship between creatinine, cystatin C and GFR. The correlation coefficients (R2) for the relationship of 1/Cr to DTPA-GFR and for 1/cystatin C to DTPA-GFR were 0.63 and 0.58, respectively. There was no significant difference between serum cystatin C and serum creatinine as markers of GFR. Serum cystatin C, which costs more to measure than serum creatinine, offers no advantage in monitoring the renal function of pediatric renal transplant recipients.

Atorvastatin treatment for hyperlipidemia in pediatric renal transplant recipients.

The objective of this prospective study was to determine the prevalence of hyperlipidemia in our pediatric renal transplant patients and to treat those with persistently elevated cholesterol and/or low-density lipoprotein (LDL) levels. All patients with a functioning renal allograft for greater than 6 months were studied (n = 18). Patients with cholesterol and/or LDL levels greater than the 95th percentile (n = 9) were commenced on an HMG-CoA reductase inhibitor, Atorvastatin and monitoring was performed for efficacy and adverse effects. Total serum cholesterol was elevated in 11 of 18 (61%) and triglyceride (TG) was elevated in 12 of 18 (67%) patients. Atorvastatin treatment was effective with a mean percentage reduction of total cholesterol of 41 +/- 10% (p < 0.01 vs. before treatment), LDL 57 +/- 7% (p < 0.01 vs. before treatment) and TG 44 +/-25% (p = 0.05 vs. before treatment). No adverse effects on allograft function or cyclosporin levels were experienced. Hyperlipidemia is a common problem and Atorvastatin is a safe and effective treatment in pediatric renal transplant recipients.