Functional and structural abnormalities of the kidney and urinary tract in severely malnourished children - A hospital based study

Objectives: The association of malnutrition and systemic diseases like chronic kidney disease [CKD] is well known. Various urinary tract abnormalities may be associated with malnutrition. So objective of current study was to determine the frequency of functional and structural urinary tract abnormalities in severely malnourished children admitted in Nutritional Rehabilitation Unit [NRU] of a tertiary care facility, Karachi

Methods: This descriptive cases series of 78 children was conducted in NRU from October 2014 - March 2015. All newly admitted children aged 2-60 months, diagnosed as Severe Acute Malnutrition [SAM] were studied and children with known kidney and urinary tract disorders were excluded. Detailed history, examination and investigations like serum creatinine, ultrasound kidney and urinary tract in addition to routine tests for SAM, were done. A proforma was used to collect demographic data, clinical history, physical findings, and radio-imaging and biochemical investigations. Glomerular filtration rate [GFR] was calculated using Schwartz equation. Data was analyzed using descriptive statistics

Results: Among 78 children, male to female ratio was equal. Mean age was 18+/-15.53 months and majority [79.48%] of children were below 24 months. Majority [82%] of children with SAM had marasmus whereas 18% had edematous malnutrition. Out of 78, 57 [73%] children had either functional [80.7%] and or structural [19.3%] abnormalities whereas 21[36.84%] had normal functional and structural status. Most common functional abnormality was subnormal GFR [<90ml/min/1.73 m[2]] found in all 46 children. Functional abnormities were more common in children below 24 months. Other functional disorders were Bartter syndrome, renal tubular acidosis and urinary tract infection [UTI] found in two cases each. Common structural abnormalities were echogenic kidneys [n=4, 36%], hydronephrosis [n=3, 27%], hypoplastic kidneys [n=3, 27%] and calculi [n=1, 9%]. Subnormal GFR was also found in all cases with structural abnormalities. UTI was observed exclusively in two children among 11 with structural abnormalities

Conclusion: A high frequency of functional abnormalities and noticeable proportion of structural abnormalities of urinary tract were detected in children with SAM. Current finding suggest that multicenter study at national level may be undertaken to generate better data about prevalence of renal diseases in SAM

Frequency of stillbirths in a tertiary care hospital of Karachi

Background and Objective: Pakistan accounts for the highest stillbirth rate in the world. Therefore, this observational study was planned to determine the prevalence of stillbirths and its associated demographic characteristics in the given context. Hence our objective included: To determine the frequency of stillbirths with reference to parity and gestational age in a tertiary care public hospital, Karachi. To determine the socio-demographic characteristics of families with stillbirths

Methods: All pregnant mothers who delivered stillbirth babies at Gynaecology and Obstetrics ward of Jinnah Postgraduate Medical Center, Karachi a tertiary care facility were prospectively enrolled from October 2012 to September 2013. Deliveries occurred before 28 weeks of gestational age were excluded. Gestational age was confirmed from hospital record and attending physicians. Data was collected on predesigned proforma and analyzed using descriptive statistics

Results: Among 7708 registered deliveries, 137 were stillbirths. A total of 84 mothers were primiparous and 12% of mothers were below 20 years at the time of delivery. Majority of stillbirths were macerated type [80.3%] and 20% were fresh stillbirth. About 55% of still births occurred between 33-37 weeks and 20% between 28-32 weeks. Almost 80%[109] of stillbirths were low birth weight and only 20%[28] were normal birth weight

Conclusion: This study shows that stillbirths are more common in primiparous mothers in a given context. Conducting awareness sessions with special focus on antenatal and obstetrical care of primiparous may be helpful to reduce still births

Zinc supplement in reduction of relapses in children with steroid sensitive nephrotic syndrome

To determine whether Zinc supplementation could reduce relapse rate in children with nephrotic syndrome. Randomized-controlled trial. National Institute of Child-Health and The Kidney Centre, Karachi, from January 2008 to June 2009. Sixty nephrotic children aged 2 - 15 years were selected. Baseline data including age, number of infections and relapses during pre and post study one year were recorded. Randomization was done to divide into Zinc group [Zg] to receive Zinc versus placebo [Pg] for 6 months. Relapses and infections were treated with standard therapy. T-test and chi-square tests were used to compare the mean values and proportions respectively with significance at p < 0.05. Among 60 children, 54 completed trial [Zg = 25, Pg = 29]. Forty [74%] were males and 14 [26%] females. Mean age, pre study relapses and Zinc level in the two groups were similar. Overall, infections and relapses were observed in 43 [79.62%] and 17 cases [31.48%] respectively. There was no significant difference in frequency of infections and mean infection rate in Zg [20, 80% and 1.92 +/- 1.47] compared to Pg [23, 79.3% and 2 +/- 1.53, p = 0.950]. Relapses occurred in 7 [28%] in Zg compared to 10 [34%] in Pg which was not significant [p = 0.609]. Mean infection and relapse rate per patient per year [PPPY] in Zg was 1.92 +/- 1.47and 1.14 +/- 0.37 compared to 2 +/- 1.53 and1.3 +/- 0.48 in Pg respectively [p=0.846, 0.464]. Pre study relapses in two groups were similar [Zg vs. Pg = 96 vs. 96.6%] whereas post study relapses in Zg were lower [7, 28%] compared to Pg [10, 34.5%]. Post study mean relapse rate in Zg was 1.14 +/- 0.37 PPPY compared to 2.71 +/- 1.11 in pre study [p = 0.005]. In Pg, post study mean relapse rate PPPY was 1.30 +/- 0.48 compared to 1.70 +/- 0.48 in pre study period [p = 0.037]. Relapse rate reduction was 43% after Zinc supplementation compared to 27% reduction in placebo. Metallic taste was observed in 10% of cases. Zinc supplementation was helpful in reducing relapses in nephrotic syndrome

Spectrum of infections in children with newly diagnosed primary nephrotic syndrome

Children with primary nephrotic syndrome are more susceptible to bacterial infections which may trigger disease or relapse or cause steroid resistance in these children. To determine the spectrum of infections in children with newly diagnosed primary nephrotic syndrome. A Retrospective case record analysis was carried out in the department of Pediatric Nephrology, National institute of child health [NICH], Karachi from January 2007 -December 2008. Patients with newly diagnosed primary nephrotic syndrome who presented with various bacterial infections were included in the study. Data for age, gender, type of infection were computed on SPSS -10 and analyzed using descriptive statistics. A total of 355 children with renal problems were registered during the study period, out of which 155 were newly diagnosed primary nephrotic syndrome. Sixty [38.7%] children had one or more infections at the time of admission. There were 34[56.7%] boys and 26[43.3%] girls whose ages ranged from 1-15 years [mean 5.22 years]. Majority of patients [36] were below 5 years of age and 24[40%] were above 5 years. Acute respiratory tract infection and urinary tract infections were the most common infections found in 28[46.6%] and 15[25%] cases respectively. Common clinical presentation was edema [100%] followed by fever in 52[86.6%], cough in 28[46.6%], urinary symptoms in 12[20%], vomiting in 8[13%] and diarrhea in 7[11.6%].One patient presented with convulsions. For children presenting with primary nephrotic syndrome, acute respiratory infection and urinary tract infections should be kept as the commonest reason for infection

Urinary citrate level in urinary stone formers versus controls

To determine the urinary citrate [UC] level in stone formers [SF] versus controls. Case control study. Department of Pediatric Nephrology, National Institute of Child Health [NICH], Karachi from January- July 2008. Eighty six children of 1-13 years, 43 in each group, stone former [SF] and controls were studied. In both groups, 24-hours UC was measured by citrate lyase method. Hypocitraturia was defined as 24- hours UC-level < 5mg/kg for children under 9 years and <7mg/kg for 9 years and above. Data including age, sex, weight, 24-hours urine volume [UV] and UClevel were analyzed using descriptive statistics on SPSS version 15. Of the 86 children, 59 [68.6%] were males and 27 [31.4%] females. Overall mean age was 5.65 + 3.05 years, while that of SF and controls was 5.61+ 3.1 and 5.70 + 3.04 years respectively. Mean 24-hours UV and UC-level in total of 86 samples was 385.10+130 ml and 88.10 + 62.11mg respectively. Mean + SD 24-hours UC-level [mg] in SF and controls was 69.4 + 53.55 [95%CI 53.39-85.41] and 106.8 + 65 [95%CI 87.37-126.23] respectively. Overall hypocitraturia was found in 42[48.8%] children. Frequency of hypocitraturia was high in SF [n 30, 69.8%] compared to controls [n 12, 27.9%] with a significant difference between the two groups [p<0.001]. Overall hypocitraturia was found in 48.8% of cases. Though hypocitraturia was prevalent in both groups, but was significantly high [69.8%] in SF compared to controls [27.9%]. Hypocitraturia may be an important metabolic risk factor and urinary citrate level should be included in the metabolic evaluation in all stone formers

Complications of acute peritoneal dialysis in children with acute kidney failure

Acute kidney injury is the sudden failure of kidneys to maintain body homeostasis and acute peritoneal dialysis is a life saving bedside mode of its management. However, complications like peritonitis, leakage, obstruction and malposition of catheter can occur during acute peritoneal dialysis. To document the immediate complications of acute peritoneal dialysis in children having acute kidney injury. Descriptive case series done at department of Pediatric Nephrology, National Institute of Child Health Karachi from July 2007 - July 2008. Children between 1 month to 14 years of age who had acute kidney injury and underwent acute peritoneal dialysis were included in the study. All had standard indications for dialysis, catheter insertion technique and manual exchanges. Data including age, gender, indications, cause of acute kidney injury and complications, were computed on SPSS - 10 and analyzed using descriptive statistics. A total of 126 children underwent acute peritoneal dialysis for various indications and among them 60 developed different complications. There were 34[56.6%] boys and 26[43.3%] girls with a mean age of 4.7 years. Indications for acute peritoneal dialysis were oligo-anuria in 52[86.6%], metabolic acidosis in 42[70%], fluid overload in 32[53.3%], uremia in 27[45%] electrolyte imbalance in 17[28.3%] and severe hypertension in 2[3.3%]. Etiologies for acute kidney injury were sepsis in 15[25%], renal calculi in 14[23.3%], congenital obstructive uropathy in 10[16.7%], acute gastroenteritis in 7[11.7%] and hypoplastic kidneys in 6[10%] cases. Mean duration of acute peritoneal dialysis was 5.2 days. Documented complications were peritonitis in 19[31.7%], catheter obstruction in 13[21.7%], leakage and catheter displacement in 11[18.3%], bleeding and other complications in 3[5%]. Acute peritoneal dialysis is a life saving procedure. Peritonitis, catheter obstruction, leakage and displacement were the common complications. Peritoneal dialysis for children should be available at all tertiary care hospitals and its staff should undergo regular training to manage the complications

Outcome of pediatric renal biopsy with monopty gun technique

To determine the outcome of percutaneous renal biopsy [PRB] using Monopty-gun technique [MGT] and to compare the results of sedation with general anesthesia [GA] used for the procedure. Descriptive Study. Department of Pediatrics at National Institute of Child Health [NICH] and the Kidney Center Postgraduate Training Institute [KPTI], Karachi from June 2005 to February 2010. Renal biopsies were performed either under sedation /GA at NICH and KPTI respectively using MGT under ultrasound guidance [USG] after routine tests. A resident/ nurse monitored the procedure. Data including age, sex, indication, vitals monitored, number of attempts per patient, glomeruli per biopsy and complications were recorded. Using statistical-Package-Scientific-Software [SPSS] version- 15, descriptive statistics were applied. Paired test was used to compare pre-and- post procedure vitals. P<0.0 was considered significant. A total of 147 biopsies in 145 children were performed. Boys were 79 [54.58%] and girls 66 [45.51%]. Mean age was 7.31 +/- 4.23 years. Most of the procedures were performed under sedation [n 105, 71.42%]. Indication were nephritic syndrome [NS] in 96[65.3%], secondary glomerulonephritis [SGN] in 17 [11.6%], nephritic-nephrotic syndrome [NNS] in 16 [10.9%], congenital nephritic syndrome [NS] in 15[10.2%] and others 3[2.06%]. The success and adequacy rate was 95.91% and 95.23% respectively. Failure occurred in 5[3.4%] cases. Overall, 26[17.68%] complications were observed in 21[14.28%] patients with 6[4%] being major. Technique related complications [20, 76.92%] were more than sedation/GA related [SGRC-n 6.23%]. The complications were more in sedation but the outcome was better in GA. MGT is a safe for PRB in children. The success, adequacy and complication rates in our study are in uniformity with the current standards

Assessment of nutritional status in children attending attending basic health unit of Shidi Goth

Shidi Goth is a slum area at a distance of 35 km. from Karachi and has a population of 10,000, mostly Sindhi and Balochi speaking inhabitants. The population belongs to low socioeconomic strata with low educational background. Assessment of nutritional status and associated factors in children attending basic health unit of Shidi Goth was a joint program of Bin Qasim and National Institute of Child Health, Karachi for primary health care system and community development. To assess nutritional status of children attending Basic Health Unit [BHU] of Shidi Goth. Cross - sectional study done in Basic Health Unit of, Shidi Goth from January, 2004 -December, 2004 uses simple random method. The sample size 78 at 95% confidence level was calculated using computer package, EPI-Info, version 5.0. Seventy eight children [35 male and 43 female] representing 78 households, suffering from various diseases who attended the Basic Health Unit of Shidi Goth were included in the study. A questionnaire was used to interview the parents of the children after a formal verbal consent, regarding number of family members, their social habits, socioeconomic and educational status, common diseases found in children up to 4 years of age, their vaccination status and information about going to school or otherwise, residing in the same house. Of 78 children 44 [56.4%] were up to 1 year of age. Common diseases in children included acute respiratory infections and gastroenteritis. Majority 67 [88.5%] had complete vaccination and only 9[11.5%] were partially vaccinated. Low weight for age was observed in 61[78%] children while severe stunting was found in 34[43.6%] and 5[6.4%] manifested severe wasting. Regarding socioeconomic status of the households, 45[58%] of the families had income less than Rs5,000/month. Average family size was 10/family. Single room occupancy was seen in 32[41%] households and basic facilities i.e. water, electricity, gas and sanitation were available in 48[61.5%] houses. Educational status of the parents was low as 35[45%] fathers and 58[75%] mothers were illiterate. Cigarette, pan and gutka were commonly consumed by the parents. Malnutrition was a major health problem and low education level of parents, large family size and low family income were the factors, contributing to low nutritional status of the children

Infections in chlidren with nephrotic syndrome

To determine the different types of infections in nephrotic children and their association with the activity of disease. Design: A descriptive study. Place and Duration of Study: It was carried out at National Institute of Child Health [NICH], Karachi from August 1995-July 1996. Patients and All children with nephrotic syndrome who had various infections during the study period were evaluated for the activity of disease and type of infections. Out of 62 children with nephrotic syndrome having infections, 45 [72.58%] were boys and 17 [27.42%] girls in a ratio of 2.5:1. Out of them 53 [85.45%] were known nephrotics and 36 [58%] of them were on steroid therapy. Nine were new cases and had not received steroids. A total of 74 episodes of infections were observed in 62 children. Acute respiratory infections [ARI] and skin infections were the most common [29.27% and 27.02% respectively] followed by diarrhoea [13.51%], UTI [12.5%] and peritonitis [10.81%]. Two patients had pulmonary tuberculosis and 3 patients had more than one infection [cellulitis, peritonitis and pneumonia]. All children with cellulitis and peritonitis were in active disease, whereas more than 80% of patients with ARI, diarrhoea and UTI were having either relapse or had recent onset of disease. The study showed that ARI, cellulitis and diarrhoea were most common infections followed by UTI and peritonitis. Majority of the infections [>78%] were associated with active disease