[Therapeutic aspects of acute renal failure in children]. / Aspecte terapeutice în insuficienta renala acuta la copil.

This article presents the results of a study on 20 children diagnosed with acute renal failure and treated with renal substitution methods at the Iasi IVth Clinic of Pediatric Nephrology in the interval 2003-2008. Treatment by intermittent hemodialysis IHD), peritoneal dialysis (DP), and continuous replacement--hemofiltering (HF) depends on the patient's features and unit resources. The advantages and limitations of every method of treatment are discussed. Future therapies for acute renal failure may find strategies for eliminating the inflammatory response.

[Considerations based on the etiology of acute renal failure in children (study on 110 cases)]. / Consideratii asupra etiologiei insuficientei renale acute la copil (studiu pe 110 cazuri).

The Article highlights the fact that without a homogeneous definition of acute renal injuries of adults and infants, for the last 5 years a new classification system has appeared. The RIFLE pediatric criteria are looked over, validated in 2007 which allow a better IRA classification at infants and allow comparisons between the intensive care units and also allow assumptions on the predictions of the disease. The list of certain causes of IRA at infants is rendered, the genetic background of children with IRA risk is highlighted, the necessity of reevaluating and criteria of evaluating renal functions is underlined. The etiology of renal failure was studied on 110 infants interned on a period of 5 years (2003- 2008) in 2 centers with different profile: The Clinic Of Pediatric Nephrology "Sf. Maria" Iasi and the Intensive Care Compartment of The Pediatric Hospital "Sf. Ioan" Galati.

[Height and weight growth delay and protein-energy malnutrition in children with chronic dialysis]. / Retardul staturo-ponderal si malnutritia protein-calorica la copilul dializat.

UNLABELLED: Growth retardation is an important problem in children with chronic renal disease, and malnutrition is a determinative factor. AIM: The study intends to assess the relationship between protein-energy malnutrition and stature-weight retardation in children enrolled in chronic dialysis program. MATERIAL AND METHOD: The study group was composed of 16 children (5 boys and 11 girls--sex ratio of 2.2) hospitalized in the IVth Nephrology Clinic at Clinical Emergency Hospital "St. Maria" Iasi, 13 rural and 3 urban, aged between 9 and 17 years, with chronic dialysis program. This was a follow-up study during a period of 4 years (2006-2009), resulting in correlations between anthropometric paremeters, biochemical, BIA and DEXA data. RESULTS: The stature-weight deficiency of the 16 patients was as follows: after an average period of 61.7 months of HD and 32.7 months of PD, in children older than 12 years (mean age 15.27 years), 7 of 10 had stature-weight deficits higher than (-3DS) or (-4DS). The group with less than (-2DS) stature-weight deficits showed the same mean age of 15.2 years, the protein energy-malnutrition was present in 2 cases (33%) and was attributed to a dialysis period shorter than 13.8 months. CONCLUSIONS: The late diagnosis of the disease (at an average age of 13 years), the long period of chronic dialysis program (over 39.5 months on average) and the early debut of malnutrition are favoring or worsening factors of stature-weight retardation. After correlating ESG with biochemical, BIA and DEXA data, in our group were identified 4 cases of moderate malnutrition and 9 cases of severe malnutrition.

[Characteristic features of urinary tract infection in malnourished children]. / Particularitatile infectiei urinare la malnutriti.

UNLABELLED: The aim of this study is to prove a relationship between urinary tract infection and malnutrition in children 0-3 years old, hospitalized in the IVI Pediatric Clinic, Hospital St. Mary Iasi, between January 2000 and December 2004. MATERIAL AND METHODS: We have made a retrospective study for 298 infant and young children with urinary tract infection, 237 eutrophic and 61 malnourished. We studied comparatively the both groups with urinary tract infection (UTI), and we applied statistic methods for results. RESULTS: The statistic methods prove that relative risk for UTI increases in malnutrition, predictive positive value is 72.5%. The clinical manifestation is similar in malnourished and eutrophic, but many co morbidities were associated with dystrophic status. Malformation of urinary tract was associate two times more in malnourished child. The etiology of infection was dominated by Escherichia coli, Proteus and Klebsiella pneumoniae. In malnourished children 5% of UTI was determinate by opportunist etiological agents like: Enterobacter, Enterococcus, Acinetobacter. More frequently, bacterium develops resistance of antibiotics like amino-penicilina, Trimethoprim and Cephalosporin. CONCLUSION: Accurate and fast diagnosis and treatment of UTI in infant and child with malnutrition is the best way for nutritional rehabilitation and prevention of serious consequence.

[Henoch-Schonlein nephritis: diagnosis and prognosis problems in childhood]. / Nefrita Henoch-Schonlein: probleme de diagnostic si prognostic la copil.

UNLABELLED: Henoch-Schonlein purpura (HSP) is the most common vasculitis in childhood and is characterized by sistemic leukocytoclastic angiitis, mainly affecting small vessels of the skin, joints, gastro-intestinal tract and kidneys. Renal involvement is the most important cause of morbidity and mortality in patients with HSP. The aim of this study was to evaluate renal involvement in children with HPS and the prognoses of short- and long-term outcome of patients diagnosed with HS nephritis. MATERIAL AND METHOD: We conducted a retrospective study based on observation files of hospitalized children with Henoch-Schonlein purpura admitted in the Nephrology Department" Sf. Maria" Hospital, during 20 years. RESULTS: The results showed that the prognosis of Henoch-Schonlein nephritis is relatively good and long-time morbidity is predominantly associated with initial presentation and renal involvement.

Nephrotic syndrome from the genetic point of view.

Nephrotic syndrome, an entity described at the beginning of the 20th century, has still an unclear pathophysiology, genetic and immunologic factors being incriminated. Here we report three cases of nephrotic syndrome with genetic involvement. The article presented tremendous progress that have been made over the past few years in enhancing our understanding of the slit-diaphragm and podocyte biology and genetics involvement in nephrotic syndrome.

[Factors influencing responsiveness to treatment in children with renal anemia in end stage renal disease]. / Factorii care limiteaza raspunsul la tratament la copiii cu anemie secundara insuficientei renale cronice terminale.

UNLABELLED: Human recombined erythropoietin had proven its efficiency in the treatment of anemia in chronic dialyzed patients and allows the elimination of complete necessity of transfusion. PURPOSE: We proposed ourselves to identify the factors that limit the answer to the combined treatment with iron and erythropoietin in a group study of 71 children diagnosed with ESRD in the IVth Pediatrics Clinic and included in the chronic dialysis program. MATERIAL AND METHOD: We divided the patients in three groups, in relation to the time in which the patients had reached and maintained the hemoglobin value of 10.5 g/dl under sustained iron treatment, combined with EPO. We analyzed the correlations established between responsively/non-responsively to treatment and the medium value of Hb, Ht, reticulocytes number, plasma value of iron and ferritin, the parameters of phospho-calcium metabolism, malnutrition as presence and degree, the age of entrance in dialysis and the duration of renal function support. RESULTS: We observed that Hb and Ht have low medium values (Hb-8.44 g/dl, Ht-25.65%) in the non-responsive group, by comparison to the responsive patients group (Hb-10.98 g/dl, Ht -32.31%). The most elevated values of iPTH around 420 pg/ml and the most frequent cases of protein-caloric malnutrition (26.8%) are seen in the non-responsive group to EPO treatment. The age of 13 years old at the entrance in the chronic dialysis program and the time of support of renal function over 21 months are seen in the non-responder group. CONCLUSION: We consider the secondary hyperparathyroidism, the protein-caloric malnutrition, the older age in the moment of entrance in dialysis and the long time of support of renal function factors that are able to influence, in a negative manner, the response to this treatment.

[Urinary tract infections in children--aspects of microbiological diagnosis]. / Infectia urinara la copil aspecte ale diagnosticului bacteriologic.

UNLABELLED: Urinary tract infection (UTI) is one of the most common bacterial infections of childhood, with the incidence range between 1-1.5% in boys and 3-8% in girls. AIM: To estimate the value of urine analysis (bacteriology and biochemistry) for diagnostic of UTI in children. MATERIAL AND METHOD: The method was to observe 700 urinary specimens collected from patients hospitalized in 4th Clinic of Pediatric Nephrology between October 2004 and February 2005, the urinalysis (UA) being performed in the Microbiology laboratory of "St. Maria" Emergency Children Hospital Iasi. The sample collection was made from the midstream urine flow, direct microscopy and standard culture were performed immediately after collection. We applied a diagnostic strategy study in order to evaluate sensitivity and specificity of UA for prediction of UTI. The data was assessed according to the Receiver Operator Characteristic Curve. RESULTS AND DISCUSSION: We analysed the relation between leukocituria and positive urine culture and we find a sensitivity equal to 56%, with CI 95% = 0.56 +/- 0.07, and a specificity equal to 10%, with CI 95% = 0.10 +/- 0.02. The likelihood of UTI with negative UA result has been calculated as a negative likelihood ratio = 4.4. If we supplement a number of culture (2-3) we have obtain a sensitivity 97% +/- 0.02%, and the predictive negative value 97% (that mean the possibility to lose UTI in just 3% cases), and a specificity 35%, with a predictive positive value 61% (that mean a decrease of possibility to over-measure UTI). CONCLUSIONS: The sensitivity of UA increase if we correlate more than leukocyturie and the significantly positive urine culture. We must to supplement a number of urine culture for increase the chance to obtain a positive diagnostic of UTI, and to exclude a possibility to over-measure UTI. Through increase a sensibility of method for diagnostic, decrease the possibility to loose and no treaty UTI with serious consequence.

[A preliminary clinical study of the metabolic syndrome in children]. / Studiu clinic preliminar asupra sindromului metabolic la copil.

UNLABELLED: The aim of the study was to identify and evaluate the metabolic syndrome of overweight children admitted in last 12 month at the 4th Department of Paediatrics. MATERIAL AND METHODS: The study included 21 overweight children aged between 5 to 18 years old. The parameters that we considered were demographics, anthropometrics, biochemical and cardiovascular. RESULTS: Metabolic syndrome was present in 11 of 21 cases (52.38%). The female gender, children with BMI > 95 percentile and people with low level of socioeconomic status were predominantly affected. A pathologic body mass index (BMI) is highly associated with borderline hypertension in 47% of cases, impaired glucose tolerance in 42% of patients and less with the presence of dyslipidemia (just 23% of patients had abnormal level of HDL-cholesterol, 14% the level of triglycerides above normal and all of them had normal value of the LDL-cholesterol). The obese and overweight children had abdominal obesity (81% of cases). The patients with abnormal value of the IMT had low level of HDL-cholesterol, impaired glucose tolerance and borderline hypertension. CONCLUSION: The determination of the carotid intima-media thickness (IMT) is a valuable method for the management of the children with metabolic syndrome and it has to be performed to all overweight children. Because the strong correlations between the different components of the metabolic syndrome, all of these patients have to be evaluated correct and complete.

[Etiology and blood pressure patterns in secondary hypertension in children]. / Studiul etiologiei si caracteristicilor hipertensiunii arteriale secundare la copil.

UNLABELLED: Most studies regarding the etiology of hypertension in children have found a frequency of secondary hypertension 4 to 9 times greater the than in adults (70-90% vs. 10%), with a probability of identifying an underlying disease inversely related with the age and directly related with the severity of hypertension. MATERIAL AND METHOD: The purpose of this study is to establish the causes and the patterns of hypertension in a group of 256 children, admitted during a five-year period in the Children's Hospital "Sf. Maria" Iasi, Romania. RESULTS: The frequency of secondary hypertension is 4 times greater than essential hypertension. The most frequent causes of secondary hypertension are renal parenchymal disease (83.2%) and cardiovascular disease (coarctation of the aorta) (11.4%); less frequent have been diagnosed neurologic (1%) and endocrinologic diseases (1.5%). Most of the assessed cases (referred to our hospital for different other reasons) have been found with stage 1 and 2 of hypertension right from the moment of admission (88.3%). We established a statistically significant relationship between the severity of hypertension and the secondary type of hypertension, meaning : the higher the blood pressure (BP)--the higher chances of diagnosing an underlying cause of hypertension. Among the secondary causes, the renal or non-renal etiology did not significantly influence the BP values at the moment of admission. Among the different histological types of chronic glomerulonephritis, focal segmental glomerulosclerosis presented with a significant higher BP comparing with the other types. CONCLUSION: the frequency of hypertension increased with age: 92.6% of essential hypertension cases belong to age 11-18, 59.2% of renal hypertension cases belong to age 11-18. The exception came from cardiovascular hypertension, which fit into age group 0-6 year old (p < 0.05%). The gender had no significant influence of the etiology of hypertension.

[Arterial stiffness in pediatric hypertension]. / Complianta vasculara în hipertensiunea arteriala la copil.

Non invasive assessment of large arteries structure and function is a valuable tool for early detection of athero/arteriosclerosis and the cardiovascular risk. The vascular injury is mainly represented by increased arterial stiffness (increased pulse wave velocity--PWV), increased peripheral arteries reflectivity (Aix) and the occurrence of significant atheromatosis (increased clMT). Although well described in adult, there are few data in children regarding the impact of uremia on vascular structure and function. This paper is an overview of the main determinants of arterial compliance in children, focusing on recent data describing the repercussions of hypertension and renal failure in this age group. To date, our group has performed the only case control study in children in order to describe the arterial stiffness, the reflective properties of peripheral arteries as well as the carotid intima-media thickness on 18 children under chronic dialysis treatment (hemodialysis and peritoneal dialysis). Comparing with control cases the dialysed children had a significantly higher PWV and Aix, which reinforce that uremia is associated with arterial stiffness even in children. There were no significant differences on IMT and PWV between hemodialysed and peritoneal dialysed children. In contrast with adult patient data, there was no favourable impact of hemodialysis session over PWv and Aix.

[The TB infection in children with chronic renal diseases]. / Infectia TBC la copiii cu boli renale cronice.

UNLABELLED: The incidence of tuberculosis in the general population has risen in Romania over the past years. It is, therefore, presumable that this incidence is higher in the immuno-compromised hosts than in the general population. METHODS: We analysed the tuberculosis incidence in children with a chronic renal disease, the favourable factors, and also the tuberculosis impact on the evolution of the renal disease. The tracing period was of 12 years, the lot being composed of 168 patients: 96 with primitive or secondary chronic renal diseases who were treated with immunosuppressive agents and 72 with ESRD, undergoing chronic dialysis. The study traced: the main disease, the immunosuppressive therapy received at the time of the TB diagnosis, the age of the main disease at the time of the TB diagnosis and its evolution stage, the proper framing within the disease type. RESULTS: There were 22 cases of tuberculosis diagnosed (22.03%), 2 ending in deaths. 10 were TB-infected (positive tuberculin skin test-TST) and 12 had TB-disease (5 cases of pulmonary and 6 of extra-pulmonary TB). The period between the diagnosing of the renal disease and that of the TB was, in average, around 6 months (between 0-48 months). Contact with other ill persons existed in only one case. Out of the cases diagnosed with TB, immunosuppression was present as a favouring factor in 9 cases (75%)--2 cases with ESRD and 7 cases with immunosuppressive therapy for the active renal disease. 4 cases with cortico-resistant nephritic syndrome (3 cases with mesangioproliferative glomerulonephritis and one case which did not undergo biopsy) responded to the immunosuppressive treatment after the tuberculostatic treatment. CONCLUSION: The tracing of the TB infection is compulsory in the groups of patients presenting risks, even in the absence of suggestive epidemiologic data. Tuberculosis induces resistance to the immunosuppressive therapy, the remission being dependent on the efficiency of the tuberculostatic treatment.

[A possible prognosis score in corticosteroid-resistant nephrotic syndrome]. / Un posibil scor prognostic în sindromul nefrotic corticorezistent.

Chronic glomerular nephropathies in children are marked by an often unfavourable evolution, so that the establishing of a prognosis at the time of the diagnosis is both a professional and a moral duty for the pediatric nephrologists. The estimation of the current practice renal survival prognosis in children with chronic glomerular nephropathies, by using clinical and laboratory elements in different histological forms of primitive chronic glomerulonephritis (CGN), with a minimum period of observation of one year. We analyzed parameters that may intervene in the duration of renal survival: type of CGN, age at the debut of the illness, histological scores of activity and chronicity, the presence of tubular atrophy lesions and that of interstitial fibrosis, renal failure (RF) installment time, in cases with normal renal function at the beginning, the time until the initiation of dialysis in cases with ESRF, respectively. The statistic analysis of data has been carried out with Epi soft (Fischer test). The results have been as follows: unfavourable evolution has been taken into consideration in the cases which have presented fixed nitric retention or which required the initiation of dialysis. The initiation of dialysis was necessary in 19 cases (76%), out of which 11 (44%) having associated between 4 and 6 of the considered risk factors. If the histological type (SFGS, DGS, MPGN) is added to the obtained score, the accuracy of the estimation increases to 89%. In conclusion, the usage of prognosis scores composed of current elements of diagnosis that have proven to have statistical significance, as far as the renal survival prognosis is concerned, may allow the invoking of a medium-term prognosis in the evolution of children with CGN.

[Treatment outcome using prednisone in corticosteroid-responsive primary nephrotic syndrome in children]. / Rezultatele tratamentului cu prednison in sindromul nefrotic primitiv cortico-sensibil la copil.

In children, the nephrotic syndrome is usually corticoid-responsive; approximately 70% of patients experience relapses, frequently triggered by infections. Our paper presents the results obtained using a 4 month prednisone regimen. This retrospective study included 83 children afflicted with nephrotic syndrome over a 10 year span. We analyzed: age at diagnosis, boys/girls ratio, response to corticoid treatment - after one month of prednisone and at the completion of the treatment course, number of relapses and their frequency, complications of prednisone treatment. The median age at diagnosis was 4.8 years, males predominating M:F = 1.5:1. Complete response after 4 weeks of prednisone therapy was noted in 98.79% of cases. We had 116 episodes of relapses during the first year of follow-up, occurring in 67.4% of children (27.9% were frequent relapsers, 11.62% subsequently became corticoid-dependent). Late relapses, after the first year, occurred in 32.55% of cases. We noted mostly mild adverse effects of the prednisone treatment: occurrence of infections during therapy (16.27%), cushingoid facies (37.2%), hirsutism (4.6%), high blood pressure (4.65%), stretch marks (2.32%). In conclusion, the 4 month prednisone treatment regimen is efficient in inducing and maintaining a remission. The incidence of relapses is 32.55%, comparable to the figure cited in larger studies. Serious adverse effects are significantly lower with this regimen compared to other corticoid treatment schemes. Key wo

[Metabolic abnormalities with hematologic manifestation]. / Anomalii metabolice cu expresie hematologica.

These are unusual diseases in pediatric pathology. We present the morphologic aspects of peripheral blood smear and bone marrow smear of nine storage disease cases.

[Remission of primary vesicoureteral reflux in children with medical management]. / Remisiunea refluxului vezico-ureteral primar sub tratament medical la copil.

We studied the spontaneous resolution rate in children with primary vesicoureteral reflux (VUR) and the interference of some specific factors. We reviewed the records of 110 children (14 days - 16 years) admitted in the 4th Pediatric Clinic Iasi with primary VUR, between 1994 - 2003, which had exclusive medical management and minimum one follow-up cystogram. We used Kaplan-Meier curves to analyze the resolution rate of VUR during the follow-up in relation with initial grade, age at diagnosis, gender, recurrent urinary tract infections (UTIs) and the presence of renal scarring. The remission rate for all the cases was 70%, with differences based on the reflux grade: 100% for grade I and 45% for grade IV. The cases diagnosed during infancy recovered faster than those diagnosed after this period. The presence of renal scarring and breakthrough UTIs increased the remission time. In conclusion the majority of patients with VUR resolved during medical management, the remission rate being influenced by the reflux grade, presence of renal scarring and breakthrough UTIs.

[Acute renal failure in children. Study of 35 patients]. / Insuficienta renala acuta la copil. Studiu pe 35 de cazuri.

The medical care of children with acute renal failure and the necessity of the substituting the renal functions has dramatically modified over the past 15 years. The study has been conducted retrospectively on 35 children diagnosed with acute renal failure (ARF), for analyzing the etiological spectrum, the evolutionary patterns and the influence factors of the ARF evolution. The following parameters have been taken into consideration: ARF etiology, hTA/HTA, oliguria, level of serum creatinine, the type of treatment (renal substitution by hemodialysis, peritoneal dialysis, or conservative treatment). The ARF etiology is dominated by the sepsis (31.4%) and by the hemolytic and uremic syndrome (17.1%). The treatment applied was conservative in 48.5% of the cases; 51.50% of the patients were in critical state and required extrarenal substitution by hemodialysis--42.8%--and peritoneal dialysis--8.5%. Global mortality is reduced (22.8%), but in the dialysed patients it is of 44.44%. The main death causes were: severe hepatic failure, oncological diseases, severe neurological damage and hemodynamic damages. In conclusion, the ARF prognosis in children is influenced by the comorbidity states. Dialysis has improved the therapeutic results in the currently presented lot, the death causes being extrarenal.

[Acute renal failure in newborn. Case presentation]. / Insuficienta renala acuta la nou-nascut. Caz clinic.

Acute renal failure in newborn occurs in 6-8%. Using a systematic approach, physicians can determine the cause of acute renal failure in most patients. Renal cortical necrosis is an uncommon cause of acute renal failure, secondary to perinatal asphyxia or severe anemia. We report our first experience in peritoneal dialysis for a newborn with renal injury due to severe bleeding through the umbilical cord.

[Management of primary vesicoureteral reflux in children]. / Tratamentul refluxului vezico-ureteral primar la copil.

The management of primary vesicoureteral reflux (VUR) in child suffered major changes by focusing on the medical treatment in order to prevent the urinary tract infections and the occurrence of postinfectious renal scars. Continuous antibiotic prophylaxis and the follow-up by serial cystography of the spontaneous resolution of the reflux are considered nowadays the best choice in most of the cases. Surgery is recommended only in selected cases. Sub-ureteral injection of bulking agents to correct the reflux holds promise as an alternative to open surgery, but presents the challenge of identifying the ideal bulking agent.

[Current aspects of hemolytic uremic syndrome in children]. / Aspecte actuale ale sindromului hemolitic si uremic la copil.

The authors are approaching the problem of hemolytic uremic syndrome, a common cause of acute renal failure in children. This review present an update about the pathophysiology of typical hemolytic uremic syndrome, useful for understanding the clinical picture and the base for some modern therapeutical models. Concerning the evolution, the authors underline the importance of identifying the risk factors for acute phase, the extrarenal manifestations being considered of vital risk. The atypical hemolytic uremic syndrome still has some uncertainties; the article try to make a synthesis of ethiopathogeneity, clinical manifestations, evolution and therapeutical modern approaches.