Activin A: a marker of mineral bone disorder in children with chronic kidney disease?

BACKGROUND: Activin A has been shown to enhance osteoclast activity and its inhibition results in bone growth. The potential role of activin A as a marker of chronic kidney disease-mineral bone disease (CKD-MBD) and its relationship with other markers has not been studied in children with CKD. METHODS: A cross sectional study was conducted among 40 children aged 2 to 18 years with CKD (Stage 2 to 5; 10 in each stage) and 40 matched controls. Activin A, cathepsin K, FGF-23, PTH, serum calcium, phosphorous and alkaline phosphatase in both groups were measured and compared. The correlation of activin A and markers of CKD-MBD was studied. A p value of < 0.05 was considered significant. RESULTS: The mean age of children with CKD was 9.30 ± 3.64 years. Mean levels of activin A in cases were 485.55 pg/ml compared to 76.19 pg/ml in controls (p < 0.001). FGF-23 levels in cases were 133.18 pg/ml while in controls it was 6.93 pg/ml (p < 0.001). Mean levels of cathepsin K were also significantly higher in cases as compared to controls. There was a progressive increase in activin A and cathepsin K levels with increasing stage of CKD. Activin A had a significant positive correlation with serum creatinine (r = 0.51; p < 0.001). CONCLUSIONS: Activin A levels progressively rise with advancing CKD stage. These findings suggest that activin A can be a potential early marker of CKD-MBD in children.

Comparison of clinical and laboratory profile of survivors and non-survivors of SARS-CoV-2-related multisystem inflammatory syndrome of childhood in India: An observational study.

AIM: The SARS-CoV-2 pandemic is characterised by multiple reports of paediatric multisystem inflammatory disease or multisystem inflammatory syndrome in children (MIS-C) with Kawasaki disease-like features often complicated by myocarditis, shock and macrophage activation syndrome. Certain clinical and laboratory markers may be used to identify high risk cases. METHODS: All sequentially admitted patients hospitalised between April 2020 and October 2020, who met the WHO case definition for MIS-C were included. Data included patient demographic information, presenting symptoms, organ dysfunction and laboratory parameters. SARS-CoV-2 infection was diagnosed by nasopharyngeal swab real-time reverse transcription-polymerase chain reaction and/or rapid antibody test for SARS-CoV-2 as recommended. The clinical and laboratory criteria were compared in the survival and non-survival groups. RESULTS: A total of 29 patients with MIS-C were treated during the study period. There were 21 survivors and 8 non-survivors. The non-survivors had more neurocognitive and respiratory symptoms along with increased incidence of myocarditis compared with survivors. The serum levels of CPK-MB, D-dimer, ferritin and triglyceride were significantly raised in non-survivors as compared to survivors. CONCLUSION: The non-survivor group had higher CPK and greater proportion of children with troponin-T elevation indicating higher incidence of myocardial injury and necrosis. The D-dimer, ferritin and triglyceride were also higher in the mortality group, indicating the greater extent of inflammatory damage in this group.

Predictors of mortality in children admitted with SARS-CoV-2 infection to a tertiary care hospital in North India.

AIM: To compare the demographic, clinical, laboratory and radiological parameters of patients with different clinical outcomes (death or discharge) and analyse them to find out the potential predictors for mortality in children hospitalised with SARS-CoV-2 infection. METHODS: Retrospective chart review of all patients less than 18 years of age with laboratory-confirmed SARS-CoV-2 infection and requiring hospital admission between 16 April 2020 and 31 October 2020. RESULTS: Of 255 children with SARS-CoV-2 infection, 100 patients (median age 62.5 months, 59% males, 70% with moderate to severe disease) were hospitalised, of whom 27 died (median age 72 months, 59% males and 30% severely underweight). The subgroup with comorbidities (n = 14) was older (median age 126 months) and had longer duration of stay (median 10 days). Fever and respiratory symptoms were comparable while gastrointestinal symptoms were more common among non-survivors. Hypoxia at admission (odds ratio (OR) 5.48, P = 0.001), multiorgan dysfunction (OR 75.42, P = 0.001), presence of acute kidney injury (OR 11.66, P = 0.001), thrombocytopenia (OR 4.40, P = 0.003) and raised serum C-reactive protein (CRP) (OR 4.69, P = 0.02) were independently associated with mortality. The median time from hospitalisation to death was 3 days. The deceased group had significantly higher median levels of inflammatory parameters and a higher incidence of complications (myocarditis, encephalitis, acute respiratory distress syndrome and shock). CONCLUSIONS: Hypoxia at admission, involvement of three or more organ systems, presence of acute kidney injury, thrombocytopenia and raised serum C-reactive protein were found to be independently associated with increased odds of in-hospital mortality in children admitted with SARS-CoV-2 infection.

Acute Kidney Injury in Hospitalized Children with COVID19.

BACKGROUND: Acute kidney injury (AKI) has been recognized as a significant risk factor for mortality among adults with severe acute respiratory syndrome coronavirus infection. AIM: The aim of this study is to assess the prevalence and risk factors for AKI and mortality in children with coronavirus disease 2019 (COVID19) from a resource-limited setting. METHODS: Cross-sectional analysis of laboratory confirmed COVID19 children admitted from 1 March to 30 November 2020 in a tertiary care hospital in New Delhi, India was done. Clinical features and associated comorbidities of COVID19 were noted. Baseline serum creatinine (height-independent Hoste's equation) and peak serum creatinine were used for staging of AKI by the 2012 Kidney Disease Improving Global Outcomes serum creatinine criteria. Univariate analysis and Kaplan-Meier survival analysis were used to compare the overall outcome in the AKI vs. the non-AKI group. RESULTS: A total of 64 810 children between 1 month and 18 years visited the hospital; 3412 were tested for suspected COVID19, 295 tested positive and 105 (54% boys) were hospitalized. Twenty-four hospitalized children (22.8%) developed AKI; 8 in Stage 1 (33.3%), 7 in Stage 2 (29.2%) and 9 in Stage 3 (37.5%) respectively. Overall, three patients received KRT. Highest reported mortality was (66.6%) in AKI Stage 3. Risk factors for AKI included associated sepsis (OR 95% CI, 1.22-9.43, p < 0.01), nephrotic syndrome (OR 95% CI, 1.13-115.5, p < 0.01), vasopressor support (OR 3.59, 95% CI, 1.37-9.40, p value< 0.007), shock at presentation (OR 2.98, 95% CI, 1.16-7.60, p value 0.01) and mechanical ventilation (OR 2.64, 95% CI, 1.04-6.71, p value< 0.03). Mortality (25.71%) was higher in the AKI group (OR 95% CI, 1.14-8.35, p < 0.023) with shock (OR 45.92; 95% CI, 3.44-612.0, p value <0.004) and ventilation (OR 46.24; 95% CI, 1.6-1333.0 p value< 0.02) as significant risk factors for mortality. CONCLUSION: AKI is an important modifiable risk factor for mortality in children with COVID19 in a resource-limited setting. Our study supports the strengthening of kidney replacement therapy and its timely initiation to reduce the progression of AKI and thus mortality in children.

Multiple Splenic Infarcts Complicating Plasmodium vivax Malaria.

Splenic infarct is a rare complication in Plasmodium vivax malaria. We report a case of splenic infarction with acute kidney injury in a case of P. vivax malaria in a 13-year-old male child who presented to the emergency department with severe pain in the left hypochondrium. The patient was managed with intravenous artesunate and oral primaquine. Pain in left hypochondrium in children with P. vivax malaria due to splenic infarction needs to be evaluated for any surgical emergency like rupture or abscess. A review of literature of the unusual but serious complication is presented along with the case report.

Hepcidin and proinflammatory markers in children with chronic kidney disease: A case-control study
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BACKGROUND: Hepcidin is the main regulator of hepcidin-ferroportin axis and is elevated in children with chronic kidney disease (CKD). Anemia of CKD and its relation to hepcidin, interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), and high-sensitivity C-reactive protein (hs-CRP) in iron- and erythropoietin (EPO)-naïve, non-dialyzed children with CKD is under-studied. MATERIALS AND METHODS: This case-control study aimed to study the levels of hepcidin and other proinflammatory markers (IL-6, TNF-α, hs-CRP) and their relation with anemia in iron- and erythropoietin-naïve, non-dialysis CKD (stage 3 - 5) patients. 32 pediatric CKD stage 3 - 5 patients aged 2 - 18 years without previous iron or EPO therapy were compared with 32 gender- and age-matched healthy controls. The CKD cases were also divided into three categories based on their serum ferritin levels and transferrin saturation (%TSAT): true iron deficiency, impaired iron trafficking, and no iron deficiency. The baseline iron status was then correlated with the serum hepcidin levels. RESULTS: Serum hepcidin, IL-6, and TNF-α levels were significantly elevated compared to controls. As CKD stage progressed, hemoglobin levels decreased, while serum hepcidin, IL6, TNF-α and hs-CRP levels increased significantly. Serum hepcidin levels correlated positively with IL-6 (r = 0.57, p = 0.001), TNF-α (r = 0.34, p = 0.05), hs-CRP (r = 0.36, p = 0.03), and ferritin (r = 0.07, p = 0.001), while being inversely correlated with Total iron binding capacity (TIBC) (r = -0.50, p = 0.003), hemoglobin (r = -0.52, p = 0.001), and glomerular filtration rate (GFR) (r = -0.71, p = 0.000). Serum hepcidin levels were highest in those with impaired iron trafficking, followed by those with no iron deficiency, followed by those with absolute iron deficiency (55.16 vs. 49 vs. 11.8, p = 0.005). Amongst those with no iron deficiency, hepcidin correlated negatively with hemoglobin (r = -0.752, p-value = 0.007). CONCLUSION: A positive correlation between hepcidin and other inflammatory biomarkers in non-dialyzed, iron- and EPO-naïve pediatric CKD patients suggests a role of these markers in higher hepcidin production and its contribution to iron-restricted erythropoiesis across the spectrum of CKD. Median hepcidin levels were highest in those with impaired iron trafficking, followed by those with no iron deficiency, followed by those with absolute iron deficiency, suggesting that in an iron-replete state, high hepcidin levels inhibit iron absorption from the gut and release from iron storing cells, thus restricting erythropoiesis leading to anemia.
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Differentially expressed urinary biomarkers in children with idiopathic nephrotic syndrome.

BACKGROUND: We performed a discovery phase of urinary proteomic profile in children with idiopathic nephrotic syndrome and validated selected biomarkers. METHODS: Urinary proteomic profile was performed using isobaric tags for relative and absolute quantitation labeling, coupled with liquid chromatography-matrix assisted laser desorption and ionization analysis. Validation of biomarkers apolipoprotein A1, alpha 2 macroglobulin, orosomucoid 2, retinol binding protein 4 and leucine-rich alpha 2-glycoprotein 1 was done by enzyme-linked immunosorbent assay. RESULTS: Apolipoprotein A1 levels of <0.48 µg/mg of creatinine-differentiated steroid-resistant nephrotic syndrome (SRNS) from first episode nephrotic syndrome, area under curve (AUC) [0.99 (CI 0.9-1.0), 100 % sensitivity and 100 % specificity] and a value of <0.24 µg/mg of creatinine could differentiate SRNS from frequently relapsing nephrotic syndrome/steroid dependent nephrotic syndrome [AUC 0.99 (CI 0.9-1.0), 100 % sensitivity and 100 % specificity]. Alpha 2 macroglobulin could differentiate children with SRNS-focal segmental glomerulosclerosis (FSGS) from SRNS-minimal change disease (MCD) at values >3.3 µg/mg of creatinine [AUC 0.84 (CI 0.62-1.0), 90 % sensitivity and 85 % specificity]. Orosomucoid 2 >1.81 µg/mg of creatinine could distinguish SRNS-FSGS from SRNS-MCD [AUC 0.84 (CI 0.62-1.0), sensitivity 90 % and specificity 85.5 %]. RBP 4 value of >1.54 µg/mg of creatinine differentiated SRNS-FSGS from SRNS-MCD [AUC 0.87 (CI 0.68-1.0), sensitivity 90 % and specificity 85.7 %]. CONCLUSIONS: Lower level of apolipoprotein A1 in urine is suggestive of SRNS. Alpha 2 macroglobulin, retinol binding protein 4 and orosomucoid 2 are markers associated with FSGS, with alpha 2 macroglobulin being most predictive.

Extending initial prednisolone treatment in a randomized control trial from 3 to 6 months did not significantly influence the course of illness in children with steroid-sensitive nephrotic syndrome.

While studies show that prolonged initial prednisone therapy reduces the frequency of relapses in nephrotic syndrome, they lack power and have risk of bias. In order to examine the effect of prolonged therapy on frequency of relapses, we conducted a blinded, 1:1 randomized, placebo-controlled trial in 5 academic hospitals in India on 181 patients, 1-12 years old, with a first episode of steroid-sensitive nephrotic syndrome. Following 12 weeks of standard therapy, in random order, 92 patients received tapering prednisolone while 89 received matching-placebo on alternate days for the next 12 weeks. On intention-to-treat analyses, primary outcome of number of relapses at 1 year was 1.26 in the 6-month group and 1.54 in the 3-month group (difference -0.28; 95% confidence interval (CI) -0.75, 0.19). Relative relapse rate for 6- vs. 3-month therapy, adjusted for gender, age, and time to initial remission, was 0.70 (95% CI 0.47-1.10). Similar proportions of patients had sustained remission, frequent relapses, and adverse effects due to steroids. Adjusted hazard ratios for first relapse and frequent relapses with prolonged therapy were 0.57 (95% CI, 0.36-1.07) and 1.01 (95% CI, 0.61-1.67), respectively. Thus, extending initial prednisolone treatment from 3 to 6 months does not influence the course of illness in children with nephrotic syndrome. These findings have implications for guiding the duration of therapy of nephrotic syndrome.

Circular right upper quadrant mass, not intussusception.

Point-of-care ultrasound is fast becoming a routine diagnostic tool in the pediatric emergency department, including in resource-limited settings. We describe a case where a patient was initially diagnosed with intussusception and admitted to a hospital. While serving as a patient model for a point-of-care ultrasound course, he was found to have a liver abscess. We discuss the manner in which the ultrasound study for ileocolic intussusception is performed and potential mimickers of ileocolic intussusception.

Subclinical non-autoimmune hypothyroidism in children with steroid resistant nephrotic syndrome.

BACKGROUND: Thyroid status has not been studied well in children with steroid resistant nephrotic syndrome (SRNS). METHODS: In this cross sectional study we recruited 20 children aged 1-16 years with SRNS and similar number of controls. Serum levels of FT3, FT4 and TSH were measured in all the subjects. Overt hypothyroidism was defined as low FT4 (normal values: 0.7-2.0 ng/mL) and elevated serum TSH above reference values (0.45-4.5 mIU/L). Subclinical hypothyroidism (SH) was defined as an elevation in serum TSH with a normal serum FT4 concentration. The primary outcome measure was serum levels of FT3, FT4 and TSH in children with SRNS. RESULTS: Thirty per cent of the children (n = 6) with SRNS had non-autoimmune subclinical hypothyroidism (2 children each with grade I, II and III). Children with SRNS had a median TSH value [3.9 mIU/L (0.5-13)] within normal range, but levels were high as compared to controls. Out of 6 children with SH, 3 were in partial remission, 3 were in complete remission. The TSH levels normalized on thyroxine supplementation in grades II and III subclinical hypothyroidism. CONCLUSION: Subclinical non-autoimmune hypothyroidism is present in a significant proportion of children with SRNS despite partial or complete remission. Thyroid profile should be evaluated routinely in this subset of patients.

Bioavailable Vitamin D Levels in Children With First Episode Nephrotic Syndrome: A Longitudinal Study.

OBJECTIVE: To estimate the levels of serum bioavailable vitamin D in children presenting with first episode nephrotic syndrome (FENS) at diagnosis and after 4 weeks of standard steroid therapy while the child is in remission, and compare the same with age-sex matched healthy controls. METHODS: We included children aged 1 month to 12 years presenting as FENS and estimated the serum calcium, phosphorus, alkaline phosphatase, 25-hydroxy vitamin D (25(OH)D), parathormone, serum and urine Vitamin D binding protein (VDBP) at diagnosis and after 4 weeks of standard steroid therapy while the child is in remission. We also included age-sex matched healthy controls for comparison. Bioavailable and free 25(OH)D were estimated at enrolment and at 4 weeks of therapy. RESULTS: The mean 25(OH)D level (ng/mL) in children with FENS was 11.3 (6.1) at diagnosis and 13.6 (6.2) at 4 weeks follow-up, while corresponding values in healthy controls was 16 (7) ng/mL. The median (IQR) serum VDBP level in FENS at enrolment was 223.0 (144, 305.5) µg/mL. There was significant correlation of serum VDBP with serum albumin levels (P = 0.04). At 4 weeks (remission), the VDBP levels increased to 554.5 (383, 644.75) µg/mL (P < 0.001). The median (IQR) free 25(OH)D levels (pg/mL) in children with FENS was 1.07 (0.8, 1.6) at enrolment and 0.53 (0.37, 0.86) at 4 weeks follow-up. The median (IQR) bioavailable vitamin D in FENS during proteinuria was 0.58 (0.4, 0.83) ng/ml, much lower as compared to controls 0.97(0.85, 1.08) ng/ml (P < 0.001). On follow-up at 4 weeks of remission the median (IQR) bioavailable vitamin D levels increased to 0.87 (0.59, 1.42) ng/ml (P = 0.015). There was a very strong positive correlation between free vitamin D and bioavailable vitamin D (r = 0.9, P < 0.001); a strong negative correlation between serum VDBP and bioavailable vitamin D (r = - 0.69, P < 0.001). There was a positive correlation between 25-hroxy vitamin D and bioavailable vitamin D (r = 0.63, P < 0.001). A positive correlation was seen between urine UP/UC and urine VDBP (r = 0.51, P = 0.004). Serum VDBP and serum albumin showed statistically significant positive correlation (r = 0.37, P < 0.05). CONCLUSION: Children with FENS are deficient in vitamin D. The free and bioavailable vitamin D levels are reduced in children with FENS during the proteinuric phase. Further studies to assess the association between bioavailable vitamin D and 25(OH)D with bone mineral density are needed in children with nephrotic syndrome to validate the utility of bioavailable vitamin D in clinical practice.

AA amyloidosis associated with systemic-onset juvenile idiopathic arthritis.

We report a 12-year-old boy with nephrotic syndrome due to renal AA amyloidosis. The AA amyloidosis was associated with a 3-year history of systemic-onset juvenile idiopathic arthritis. The presence of serum amyloid A protein was confirmed by laser microdissection of Congo Red-positive glomeruli and vessels followed by liquid chromatography and tandem mass spectrometry; this analysis excluded hereditary and familial amyloidosis. Aggressive management of the systemic-onset juvenile idiopathic arthritis resulted in improvement in clinical and laboratory parameters. The case represents an unusual cause of nephrotic syndrome in children. Early diagnosis of renal amyloidosis and management of systemic-onset juvenile idiopathic arthritis is paramount to preventing progression of kidney disease.

Hearing status in children with frequently relapsing and steroid resistant nephrotic syndrome.

BACKGROUND: Children with idiopathic nephrotic syndrome (INS) are at risk of hearing impairment due to nephrotoxic drugs and biochemical impairments. METHODS: Forty children with INS aged 5-16 years [20 patients with frequently relapsing nephrotic syndrome (FRNS)/steroid dependent nephrotic syndrome (SDNS) and 20 with steroid resistant nephrotic syndrome (SRNS)] and 20 normal healthy controls were enrolled in this study. Pure tone audiometry was done using the ALPS AD 2000 audiometer. Sensorineural hearing loss was diagnosed when the bone conduction level was >20 dB and the difference in air to bone gap was ≤15 dB. Based on the air conduction (AC) threshold, deafness was graded into the following categories: mild (26-40 dB), moderate (41-55 dB), moderately severe (56-70 dB), severe (71-91 dB) and profound (>91 dB). RESULTS: Children with FRNS/SDNS had a higher threshold for hearing at frequencies of 250 and 500 Hz, respectively, than the controls. Of the children in the FRNS/SDNS category, three (15 %) had mild sensorineural hearing impairment. These children had a low serum calcium level (P < 0.03) and received higher cumulative doses of furosemide (P < 0.04). Children with SRNS had a higher threshold for hearing at frequencies of 250, 500, 1,000, and 2,000 Hz, respectively, than the controls. Of the 20 children with SRNS, ten (50 %) had sensoineural hearing impairment (8 mild, 2 moderate). Children with SRNS with a hearing defect had received a higher cumulative dose of furosemide (P < 0.03). CONCLUSIONS: Children with FRNS/SDNS and SRNS are at risk of sensorineural hearing impairment. The risk factors associated with this impairment were higher cumulative doses of furosemide and hypocalcemia. Larger prospective cohort studies are required to evaluate this association.

Electrical injuries in urban children in New Delhi.

AIM: The objective of this study was to analyze the epidemiology, presentation, management, and complications of electrical burn injuries in urban children. METHODS: Data from records and clinical data were collected retrospectively and prospectively during 2008 to 2010. RESULTS: Of 41 children enrolled, the mean age of children enrolled was 8.1 ± 4.5 years. Low-voltage injury was seen in 28 (68.2%), and 13 (31.8%) had high-voltage injuries. Low-voltage injuries were most commonly (52.45%) secondary to direct contact with live wire, whereas high-voltage injuries in 70% were due to direct contact with broken wires lying in fields/rooftops. Fourteen children of the 41 enrolled had associated injuries. Low-voltage injuries were associated with minor burns, seizures, tibial fracture, eyelid burn, scalp hematoma, and speech and visual impairment, whereas high-voltage injuries were associated with cardiac arrest, extradural hematoma, visceral burns, pulmonary hemorrhage and hypoxic encephalopathy, and postelectrocution acute respiratory distress syndrome. Surgical interventions done included split-thickness skin grafting, fasciotomy, and amputation procedures. The mean duration of hospital stay of all the children enrolled was 9.02 days with 35 children discharged, 71.4% of them having low-voltage injuries. Four children died, 75% of them having high-voltage injury, whereas 2 children left without medical advice, both having low-voltage injuries. CONCLUSIONS: Children are a major group susceptible to electrical injuries in our country. Most of the mechanisms leading to them are easily preventable, but occur because of lack or awareness among the children and their guardians. Burn prevention program should be implemented incorporating these epidemiological data.

Integration of Urinary Neutrophil Gelatinase-associated Lipocalin with the Renal Angina Index to Predict Subsequent Severe Acute Kidney Injury in Critically Ill Children: A Diagnostic Accuracy Study.

The primary objective of this study was to determine the performance of the renal angina index (RAI) in predicting subsequent severe acute kidney injury (AKI) on day 3 of admission and whether integrating urinary neutrophil gelatinase-associated lipocalin (NGAL) with RAI would lead to improved prediction of AKI. This was a prospective observational study conducted in the pediatric intensive care unit (PICU) of a tertiary care hospital involving 170 children meeting the inclusion criteria. The RAI was assessed within 24 h of admission to the PICU. Positivity for renal angina was considered RAI ≥8. Urine samples were collected for all enrolled patients within the first 24 h and on day 3 of the PICU stay. NGAL was assayed using human-specific enzyme-linked immunosorbent assay. The overall incidence of AKI was 18.2%. Out of 170 children, 31 (18.2%) were RAI-positive on day 0. A higher proportion of patients in the RAI-positive group developed AKI on day 3 compared with the RAI-negative group (83.9% vs. 3.6%, P <0.001). Those who were RAI-positive on day 0 had a sensitivity, specificity, positive predictive value (PPV), and negative predictive value of 83.8%, 96.4%, 83.8%, and 96.4%, respectively, for predicting severe AKI on day 3. Incorporating urinary NGAL improved the specificity and PPV to 97.8% and 85.7%, respectively. Assessing the RAI is simple and useful for predicting severe AKI in critically ill children. The addition of urinary NGAL to the RAI optimizes its use for identifying patients at risk of subsequent severe AKI.

Factors Associated With Hypertension and Cardiovascular Parameters in Children With Infrequently Relapsing Nephrotic Syndrome.

OBJECTIVES: To assess the prevalence of hypertension in children with infrequently relapsing nephrotic syndrome (IRNS) and its association with dyslipidemia, and end organ damage including left ventricular hypertrophy (LVH), at relapse and after steroid induced remission. METHODS: Prospective observational study conducted in 83 children aged 1-12 years with IRNS, presenting in relapse. Blood pressure, fundus examination, blood and urine investigations were done at relapse and then at 4 weeks of therapy. Echocardiography at 4 weeks was performed for assessment of LVH and relative wall thickness (RWT) for concentric geo-metry (CG). RESULTS: 27 patients (32.5%) developed hypertension, out of which 21 patients (25.3%) had stage I hypertension. Hypertension in first episode (63.0%, P<0.01) and in previous relapses (87.5%, P<0.001) was significantly associated with hypertension in the current episode. 12 patients had a positive family history of hypertension, of which 8 (66.7%) were classified under the hypertensive group (P=0.016). Concentric geometry (CG) was found in 28% of hypertensive and 5.5% of non-hypertensive children (P=0.011). On regression analysis, a lower Up:Uc at the time of relapse was found to have a protective role for development of hypertension. CONCLUSION: One third children with IRNS had hypertension at relapse and a high proportion of hypertensive patients had CG pattern on echocardiography.

Urinary Apolipoprotein A1 and Neutrophil Gelatinase-associated Lipocalin in Children with Idiopathic Nephrotic Syndrome.

Urinary biomarkers are a promising diagnostic modality whose role was explored in nephrotic syndrome (NS). We estimated urinary apolipoprotein A1 (Apo A1) and neutrophil gelatinase-associated lipocalin (NGAL) in children with first-episode NS (FENS) and controls with a longitudinal follow-up to see the serial changes during remission. The study groups comprised 35 children with FENS and an equal number of age- and sex-matched controls. Patients were followed up at regular intervals, and 32 patients were classified as having steroid-sensitive NS (SSNS) and 3 as having steroid-resistant NS (SRNS). The mean follow-up period was 8.7 ± 4.2 months. Three patients in the SSNS group were labeled as having frequent relapses or steroid-dependent disease during follow-up. Of the three children with SRNS, two had minimal changes in the disease and one had idiopathic membranous nephropathy. The levels of Apo A1:creatinine, NGAL:creatinine, and spot urinary protein:urinary creatinine ratios were significantly higher in children with FENS compared with controls. The levels of the urine biomarkers decreased significantly at subsequent follow-up with remission. The Apo A1 and NGAL levels in SSNS patients were significantly high compared with both the controls and FENS patients. Urinary Apo A1 levels in SRNS patients were lower at initial presentation. This longitudinal study revealed changes in the urinary Apo A1 and NGAL in NS over the course of the disease.