Serum uric acid concentration is associated with lower glomerular filtration rate in children undergoing kidney transplantation.

BACKGROUND: The relationship between serum concentration of uric acid (UA) and chronic kidney disease is complex due to many confounding variables. There is currently debate over whether hyperuricemia acts as a marker of kidney disease or as an independent risk factor. OBJECTIVES: To test the impact of serum UA concentration on the estimated glomerular filtration rate (GFR) of children undergoing kidney transplantation. PATIENTS AND METHODS: Prospective longitudinal study of children and adolescents after kidney transplantation. We analyzed clinical, anthropometric, and laboratory data at pre-transplant and 1, 3, and 6 months after transplant. We developed models of repeated measures analysis, using the generalized estimating equations technique for the outcome evolution of the estimated GFR at 1, 3 and 6 months. High serum UA concentration at 1 and 3 months was modeled as the main exposure variable. RESULTS: We included 103 transplant patients. In a model adjusted for time, recipient sex and age, the occurrence of acute rejection episodes, and the estimated glomerular filtration at baseline, the trajectory of GFR exhibited an inverse relationship with UA (ß = -7.1, 95% CI: -11.5 to -2.6, p < .01). CONCLUSION: Serum UA increase was associated with lower graft function over time.

The impact of food addiction behaviours on the treatment of overweight students.

The present study evaluated the association of food addiction (FA), the change of the BMI/age z-score and the consumption of ultra-processed foods in overweight students undergoing a 16-month, multicomponent intervention in the school environment. FA was investigated using the Yale Food Addiction Scale for Children, and the dietary assessment was estimated using the semi-quantitative FFQ in overweight 9-11-year-old students (BMI/age z-score ≥ 1) of both sexes at their baseline and after the intervention (n 120). Among the schoolchildren, 33·4 % had FA in at least one of the two assessments. The analysis of mixed-effects models to assess the effect of the intervention and the change of the BMI/age z-score between evaluations showed that the occurrence of FA influenced the maintenance of weight (time#FA, ß = 0·30, 95 % CI 0·05, 0·54, P = 0·016). Weight loss was observed only in individuals who did not present FA (BMI/age z-score = -0·3). When evaluating the effect of the intervention and the dietary variables, we verified a reduction in the consumption of sugary milk-based drinks -71·13 kJ (-17 kcal), P = 0·04 only in non-FA students at the end of the study. FA has been identified as an underlying factor with therapeutic relevance, and an enhanced understanding of FA can open new paths for the prevention and management of obesity.

Access to treatment for chronic kidney disease by children and adolescents in Brazil.

BACKGROUND: This study aimed to identify main factors associated with child and adolescent access to chronic kidney disease (CKD) treatment in Brazil. METHODS: Multi-center cross-sectional study conducted in eight pediatric nephrology centers across all Brazilian geographic regions. Information was collected on characteristics associated with referral and treatment of patients with CKD. The following outcomes were analyzed as follows: (1) age at first consultation, and (2) time elapsed between referral and treatment at the specialized service. RESULTS: Three hundred thirty-five children were assessed. Variables associated with age at first consultation were as follows: CAKUT (HR=1.7; 95%CI 1.3-2.2, p<0.01); private health plan (HR=1.54; 95%CI 1.06-2.23, p=0.02); modified Medical Outcomes Study Social Support Survey mMOS-SS score (HR=1.02; 95%CI 1.00-1.03, p=0.024); maternal age (HR=0.96; 95%CI 0.95-0.97, p<0.01); and number of siblings in the household (HR=0.86; 95%CI 0.79-0.83, p<0.01). Significant variables associated with time elapsed between referral and treatment at the specialized service were as follows: each additional occupant sharing the household (HR=0.94; 95%CI:0.89-0.99, p=0.02), residing in the Northeast (HR=0.81; 95%CI:0.67-0.98, p=0.03) and having someone to take them to the physician (HR=1.36; 95%CI 1.07-1.74, p=0.01). The median time interval between patient referral and treatment by the service was 11 days (IQR 10-31). CONCLUSION: There are potentially modifiable factors hampering access of children with CKD to specialized treatment. The importance of the role of social support for the two outcomes should serve as an alert for health managers and professionals to consider this aspect throughout all steps of the care process of children with CKD.

APOL1 in an ethnically diverse pediatric population with nephrotic syndrome: implications in focal segmental glomerulosclerosis and other diagnoses.

BACKGROUND: APOL1 high-risk genotypes (HRG) are associated with increased risk of kidney disease in individuals of African ancestry. We analyzed the effects of APOL1 risk variants on an ethnically diverse Brazilian pediatric nephrotic syndrome (NS) cohort. METHODS: Multicenter study including 318 NS patients, categorized as progressors to advanced CKD [estimated glomerular filtration rate (eGFR)] < 30 mL/min/1.73 m2] and slow/non-progressors (eGFR > 30 mL/min/1.73 m2 through the study). We employed Cox regression with progression time as the outcome and APOL1 genotype as the independent variable. We tested this association in the entire cohort and three subgroups; (1) focal segmental glomerulosclerosis (FSGS), (2) steroid-resistant NS (SRNS), and (3) those who underwent kidney biopsy. RESULTS: Nineteen patients (6%) had an HRG. Of these, 47% were self-reported White. Patients with HRG manifested NS at older ages and presented higher frequencies of FSGS and SRNS. HRG patients progressed to advanced CKD more often than low-risk-genotype (LRG) children in the whole NS cohort (p = 0.001) and the three subgroups. In SRNS and biopsied patients, a single risk variant was associated with trends of higher CKD progression risk. CONCLUSIONS: Novel discoveries include a substantial prevalence of HRG among patients self-reported White, worse kidney outcomes in HRG versus LRG children in the FSGS subgroup, and a trend of higher CKD progression risk associated with a single risk variant in the SRNS cohort. These findings suggest APOL1-associated NS extends beyond patients self-reported non-White, the HRG effect is independent of FSGS, and a single risk variant may have a detrimental impact in children with NS.

EMOTIONAL REPERCUSSIONS AND QUALITY OF LIFE IN CHILDREN AND ADOLESCENTS UNDERGOING HEMODIALYSIS OR AFTER KIDNEY TRANSPLANTATION.

OBJECTIVE: To investigate the emotional repercussions and quality of life (QOL) associated with end-stage kidney disease (ESKD) in children and adolescents undergoing hemodialysis or a kidney transplant (TX). METHODS: We conducted a quantitative-qualitative study. 48 children and adolescents with ESKD were interviewed; half of them underwent hemodialysis treatment, and the other half had a kidney transplantation. Their respective 48 caregivers also participated in the study. The questionnaire involved both the Pediatric Quality of Life Inventory and a thematic story-drawing tool. An analysis of the QOL questionnaire's results was done by comparing the sum of points between groups and the theme-based story-drawing consisted of interpreting the data contained in the material using Freudian and Lacanian theories. RESULTS: In the QOL questionnaires, the total score was higher in the transplanted patients and in their caregivers, suggesting a perception of better QOL after kidney transplantation. In the specific aspects of the questionnaire, physical capacity was considered superior by children who underwent transplants and their caregivers. There were no differences between the groups in the emotional, social and school aspects. However, the caregivers of the patients who had a transplant perceived a significant difference in QOL in the school aspect. In the thematic story-drawings, emotional suffering in the two analyzed groups was evidenced regardless of the treatment. CONCLUSIONS: Despite the questionnaire results suggesting that transplantation does improve some aspects of QOL, there were no differences observed between kidney replacement therapies regarding the emotional repercussion of chronic kidney disease.

Emotional repercussions and quality of life in children and adolescents undergoing hemodialysis or after kidney transplantation / Repercussões emocionais e qualidade de vida das crianças e adolescentes em hemodiálise ou após transplante renal

ABSTRACT Objective: To investigate the emotional repercussions and quality of life (QOL) associated with end-stage kidney disease (ESKD) in children and adolescents undergoing hemodialysis or a kidney transplant (TX). Methods: We conducted a quantitative-qualitative study. 48 children and adolescents with ESKD were interviewed; half of them underwent hemodialysis treatment, and the other half had a kidney transplantation. Their respective 48 caregivers also participated in the study. The questionnaire involved both the Pediatric Quality of Life Inventory and a thematic story-drawing tool. An analysis of the QOL questionnaire's results was done by comparing the sum of points between groups and the theme-based story-drawing consisted of interpreting the data contained in the material using Freudian and Lacanian theories. Results: In the QOL questionnaires, the total score was higher in the transplanted patients and in their caregivers, suggesting a perception of better QOL after kidney transplantation. In the specific aspects of the questionnaire, physical capacity was considered superior by children who underwent transplants and their caregivers. There were no differences between the groups in the emotional, social and school aspects. However, the caregivers of the patients who had a transplant perceived a significant difference in QOL in the school aspect. In the thematic story-drawings, emotional suffering in the two analyzed groups was evidenced regardless of the treatment. Conclusions: Despite the questionnaire results suggesting that transplantation does improve some aspects of QOL, there were no differences observed between kidney replacement therapies regarding the emotional repercussion of chronic kidney disease.

RESUMO Objetivo: Investigar as repercussões emocionais e a qualidade de vida (QV) associadas à doença renal crônica em crianças e adolescentes submetidos à hemodiálise ou ao transplante renal. Métodos: Foram entrevistadas 48 crianças e adolescentes com doença renal crônica, metade dos quais submetidos ao tratamento hemodialítico, e a outra metade, ao transplante renal. Os 48 respectivos cuidadores também participaram da pesquisa. Utilizou-se o questionário de QV Pediatric Quality of Life Inventory e o instrumento de desenho-estória com tema. A análise dos resultados do questionário de QV foi feita pela somatória dos pontos e a dos desenhos-estórias com tema consistiu na interpretação dos dados do material, utilizando as teorias freudiana e lacaniana. Resultados: Nos questionários de QV, a pontuação total foi superior na opinião dos pacientes transplantados e seus cuidadores, indicando percepção de melhor QV após o transplante renal. Nos aspectos específicos, a capacidade física também foi considerada superior por esse grupo. Não houve diferenças entre os grupos de pacientes nos aspectos emocional, social e escolar, porém os cuidadores dos pacientes transplantados notaram diferença na QV no aspecto escolar. Nos desenhos-estórias com tema, observou-se que o sofrimento emocional foi evidenciado nos dois grupos estudados. Conclusões: Não foram percebidas diferenças entre as terapêuticas renais substitutivas quanto às repercussões emocionais da doença renal crônica. Por outro lado, verificou-se que o transplante melhora a QV no aspecto geral.

Non-standard criteria donors in pediatric kidney transplantation.

KT remains the treatment of choice for ESRD in children. However, the demand for kidney transplants continues to outstrip supply, even in the pediatric scenario. We reviewed the applicability of nonSCDs for pediatric KT. There is a lack of studies analyzing this modality among pediatric donors and recipients, where most conclusions are based on predictions from adult data. Nevertheless, marginal donors might be a reasonable option in selected cases. For example, the use of older LDs is an acceptable option, with outcomes comparable to SCDs. Organs donated after cardiac death represent another possibility, albeit with logistic, ethical, and legal limitations in some countries. AKI donors also constitute an option in special situations, although there are no pediatric data on these transplants. Likewise, there are no data on the use of expanded criteria donors in pediatric patients, but this appears not to be a good option, considering the compromised long-term survival.

Development of a risk score for earlier diagnosis of chronic kidney disease in children.

OBJECTIVE: To develop a clinical score for the early identification of chronic kidney disease (CKD) in children and adolescents. The early diagnosis of CKD in childhood allows the adoption of measures to slow the progression of the disease, thereby reducing morbidity and mortality. Nevertheless, the diagnosis is often made too late for proper patient management. STUDY DESIGN: We preformed a case-control study of a multicenter Brazilian sample of 752 pediatric patients; the study cases (n = 376) were CKD patients with a median estimated GFR of 37 (IQR = 22 to 57) ml/min/1.73 m2. The control group (n = 376) comprised age-, gender- and center-matched children who were followed for nonrenal diseases. Potential risk factors were investigated through a standard questionnaire that included symptoms, medical history, and a clinical examination. Two multivariable models (A and B) were fitted to assess predictors of the diagnosis of CKD. RESULTS: In model A, 9 variables were associated with CKD diagnosis: antenatal ultrasound with urinary malformation, recurrent urinary tract infection, polyuria, abnormal urine stream, nocturia, growth curve flattening, history of hypertension, foamy urine and edema (c-statistic = 0.938). Model B had the same variables as model A, except for the addition of the history of admission during the neonatal period and the exclusion of antenatal ultrasound variables (c-statistic = 0.927). CONCLUSIONS: The present scores may serve as a warning sign for CKD diagnosis in children among professionals working in the primary care setting where the symptoms associated with a risk of CKD may be overlooked.

Raquitismo hipofosfatêmico: relato de caso / Hypophosphatemic rickets: case report

RESUMO Objetivo: O raquitismo hipofosfatêmico precisa ser precocemente diagnosticado porque seu tratamento previne sequelas incapacitantes. Este relato alerta para a doença. Relato de caso: Relato de perfil metabólico, depuração de creatinina, estado nutricional e desenvolvimento pôndero-estatural de paciente com características clínico-laboratoriais de raquitismo hipofosfatêmico, atendido em ambulatório de tubulopatias por período de 12 meses. Chegou ao serviço após tempo prolongado acamado, dependente de ventilação mecânica e com perfil metabólico ósseo alterado. Terapêutica consistiu na administração de fósforo (inicial: 65 mg/kg/dia, final: 24,2 mg/kg/dia), cálcio (inicial: 127 mg/kg/dia, final: 48,4 mg/kg/dia) e calcitriol (inicial: 0,06 mcg/kg/dia, final: 0,03 mcg/kg/dia), e a análise constou da descrição das consultas, utilizando-se mediana de exames laboratoriais e dados antropométricos. Observou-se nítida melhora inicial do padrão respiratório do paciente, que evoluiu com ventilação espontânea e deambulação autônoma; com exames laboratoriais: cálcio (mg/dL) inicial 7,1, final 10,1; fósforo (mg/dL) inicial 1,7, final 3,2; magnésio (mg/dL) inicial 1,5, final 2,1; paratormônio (pg/L) inicial 85,8, final 52,7; fosfatase alcalina (UI/L) inicial 12660, final 938; e melhora do desenvolvimento pôndero-estatural (escore Z: E/I inicial: -6,05, final -3,64; P/I: inicial -2,92, final -1,57) com presença de litíase transitória. A depuração de creatinina (mL/min/1,73 m2sc) foi constante durante o seguimento. O tratamento propiciou benefícios clínicos, bioquímicos e nutricionais, mas, apesar da boa resposta inicial, a família abandonou o seguimento por dois anos, apresentando o paciente piora da deambulação e das deformidades esqueléticas. Comentários: Não apenas diagnóstico precoce é necessário, como também a adesão ao tratamento é fundamental para o sucesso na condução dessa patologia.

ABSTRACT Objective: Early diagnosis and immediate treatment of hypophosphatemic rickets is of utmost importance as it may prevent subsequent sequelae. This report aims at warning pediatricians to consider the presence of the disease. Case description: Description of the metabolic profile, creatinine clearance, nutritional status, weight and body structure of a patient who presented the clinical-laboratorial characteristics of hypophosphatemic rickets and was followed in an outpatient clinic for tubulopathies over the period of 12 months. The patient had been bedridden for some time, was dependent on mechanical ventilation and presented an altered metabolic bone condition. Treatment was phosphate (initial: 65 mg/kg/day and final: 24,2 mg/kg/day), calcium (initial: 127 mg/kg/day, final: 48,4 mg/kg/day) and calcitriol (initial: 0.06 mcg/kg/day, final: 0.03 mcg/kg/day). The patient improved, evolving into spontaneous breathing and walking unaided. Laboratory results: calcium (mg/dL) initial 7.1, final 10.1; phosphate (mg/dL) initial 1.7 final 3.2; magnesium (mg/dL) initial 1.5 final 2.1, parathyroid hormone (pg/l) initial 85.8, final 52.7, alkaline phosphatase (UI/l) initial 12660, final 938; there was also improvement in weight/structural development (Z score: H/A initial: -6.05, final -3.64; W/A: initial -2.92, final -1.57) with presence of transitory gallstones. Creatinine clearance (mL/min/1.73m2bsa) was constant. The medication improved his laboratory results and nutritional status, but the patient did not return for two years for follow-up and, during this period, his condition has noticeably deteriorated. Comments: Early diagnosis and follow-up are essential in dealing with this pathology.

HYPOPHOSPHATEMIC RICKETS: CASE REPORT. / RAQUITISMO HIPOFOSFATÊMICO: RELATO DE CASO.

OBJECTIVE: Early diagnosis and immediate treatment of hypophosphatemic rickets is of utmost importance as it may prevent subsequent sequelae. This report aims at warning pediatricians to consider the presence of the disease. CASE DESCRIPTION: Description of the metabolic profile, creatinine clearance, nutritional status, weight and body structure of a patient who presented the clinical-laboratorial characteristics of hypophosphatemic rickets and was followed in an outpatient clinic for tubulopathies over the period of 12 months. The patient had been bedridden for some time, was dependent on mechanical ventilation and presented an altered metabolic bone condition. Treatment was phosphate (initial: 65 mg/kg/day and final: 24,2 mg/kg/day), calcium (initial: 127 mg/kg/day, final: 48,4 mg/kg/day) and calcitriol (initial: 0.06 mcg/kg/day, final: 0.03 mcg/kg/day). The patient improved, evolving into spontaneous breathing and walking unaided. Laboratory results: calcium (mg/dL) initial 7.1, final 10.1; phosphate (mg/dL) initial 1.7 final 3.2; magnesium (mg/dL) initial 1.5 final 2.1, parathyroid hormone (pg/l) initial 85.8, final 52.7, alkaline phosphatase (UI/l) initial 12660, final 938; there was also improvement in weight/structural development (Z score: H/A initial: -6.05, final -3.64; W/A: initial -2.92, final -1.57) with presence of transitory gallstones. Creatinine clearance (mL/min/1.73m2bsa) was constant. The medication improved his laboratory results and nutritional status, but the patient did not return for two years for follow-up and, during this period, his condition has noticeably deteriorated. COMMENTS: Early diagnosis and follow-up are essential in dealing with this pathology.

OBJETIVO: O raquitismo hipofosfatêmico precisa ser precocemente diagnosticado porque seu tratamento previne sequelas incapacitantes. Este relato alerta para a doença. RELATO DE CASO: Relato de perfil metabólico, depuração de creatinina, estado nutricional e desenvolvimento pôndero-estatural de paciente com características clínico-laboratoriais de raquitismo hipofosfatêmico, atendido em ambulatório de tubulopatias por período de 12 meses. Chegou ao serviço após tempo prolongado acamado, dependente de ventilação mecânica e com perfil metabólico ósseo alterado. Terapêutica consistiu na administração de fósforo (inicial: 65 mg/kg/dia, final: 24,2 mg/kg/dia), cálcio (inicial: 127 mg/kg/dia, final: 48,4 mg/kg/dia) e calcitriol (inicial: 0,06 mcg/kg/dia, final: 0,03 mcg/kg/dia), e a análise constou da descrição das consultas, utilizando-se mediana de exames laboratoriais e dados antropométricos. Observou-se nítida melhora inicial do padrão respiratório do paciente, que evoluiu com ventilação espontânea e deambulação autônoma; com exames laboratoriais: cálcio (mg/dL) inicial 7,1, final 10,1; fósforo (mg/dL) inicial 1,7, final 3,2; magnésio (mg/dL) inicial 1,5, final 2,1; paratormônio (pg/L) inicial 85,8, final 52,7; fosfatase alcalina (UI/L) inicial 12660, final 938; e melhora do desenvolvimento pôndero-estatural (escore Z: E/I inicial: -6,05, final -3,64; P/I: inicial -2,92, final -1,57) com presença de litíase transitória. A depuração de creatinina (mL/min/1,73 m2sc) foi constante durante o seguimento. O tratamento propiciou benefícios clínicos, bioquímicos e nutricionais, mas, apesar da boa resposta inicial, a família abandonou o seguimento por dois anos, apresentando o paciente piora da deambulação e das deformidades esqueléticas. COMENTÁRIOS: Não apenas diagnóstico precoce é necessário, como também a adesão ao tratamento é fundamental para o sucesso na condução dessa patologia.

Signs and symptoms of developmental abnormalities of the genitourinary tract / Sinais e sintomas das anormalidades do desenvolvimento do trato geniturinário

Abstract Objective: The abnormalities of the genitourinary tract development are the leading cause of chronic kidney disease (CKD) in children. The diagnosis of this disease in Brazil is late and incomplete, which results in increased morbidity and mortality in this age group. Early diagnosis of this condition is the prerogative of generalist pediatricians, and the aim of this study was to review the clinical signs and symptoms associated with developmental abnormalities of the genitourinary tract. Data sources: Based on the description of a symbolic clinical case, the authors conducted a non-systematic review of medical literature. Data synthesis: The results suggest that the following data should be used as a warning for early diagnosis of affected children: (a) combined urinary tract abnormalities (chromosomal abnormalities; sequence of malformations [VACTERLand Prune-Belly]; and musculoskeletal, digestive tract, heart, and nervous system malformations); (b) previous history (congenital anomalies of the kidney and urinary tract [CAKUT] in the family, low birth weight, and oligoamnios); (c) clinical signs (polyuria/nocturia, urinary tract infection, systemic arterial hypertension, failure to thrive, weak urinary stream, difficulty to start urination, distended bladder, non-monosymptomatic enuresis, urinary/urge incontinence, and bowel and bladder dysfunction); and (d) pre- and postnatal ultrasonographic alterations (increased anteroposterior diameter of the renal pelvis, mainly in the third trimester of pregnancy; single kidney; hydronephrosis associated with other abnormalities; and hydronephrosis with parenchymal involvement in the post-neonatal assessment). Conclusion: The suggestions shown here can help the pediatrician to establish clinical hypotheses for the early diagnosis of developmental abnormalities of the genitourinary tract without resorting to expensive and invasive procedures.

Resumo Objetivo: As anormalidades do desenvolvimento do trato geniturinário são a principal causa de doença renal crônica (DRC) em crianças. O diagnóstico dessa doença no Brasil é formulado de maneira incompleta e tardia, o que resulta em aumento na morbimortalidade nessa faixa etária. O diagnóstico precoce dessa condição é prerrogativa dos pediatras generalistas e o objetivo deste trabalho foi revisar os sinais e sintomas clínicos associados às anormalidades do desenvolvimento do trato geniturinário. Fontes dos dados: A partir da descrição de um caso clínico simbólico, fizemos uma revisão não sistemática da literatura médica. Síntese dos dados: Os resultados sugerem que os seguintes dados devem ser usados como alerta para o diagnóstico precoce das crianças acometidas: a) anomalias do trato urinário compostas (anomalias cromossômicas, sequências de malformações – Vacterl e Prune-Belly, malformações musculoesqueléticas, do trato digestivo, cardíacas e do sistema nervoso); b) antecedentes (anomalias congênitas do rim e trato urinário (CAKUT) na família, baixo peso ao nascer e oligoâmnio); c) sinais clínicos (polaciúria/noctúria, infecção urinária, hipertensão arterial sistêmica, baixo ganho de peso, jato urinário fraco, dificuldade para iniciar a micção, bexigoma, enurese não monossintomática, urge/incontinência urinária, disfunção do intestino e da bexiga) e d) alterações ultrassonográficas ante e pós-natais (diâmetro anteroposterior da pélvis renal aumentado principalmente no terceiro trimestre da gestação, rim único, hidronefrose associada a outras anomalias e hidronefrose com comprometimento de parênquima na avaliação pós-neonatal). Conclusão: As sugestões apresentadas podem ajudar o pediatra a estabelecer hipóteses clínicas para o diagnóstico precoce das anormalidades do desenvolvimento do trato geniturinário sem metodologias caras e invasivas.

Signs and symptoms of developmental abnormalities of the genitourinary tract.

OBJECTIVE: The abnormalities of the genitourinary tract development are the leading cause of chronic kidney disease (CKD) in children. The diagnosis of this disease in Brazil is late and incomplete, which results in increased morbidity and mortality in this age group. Early diagnosis of this condition is the prerogative of generalist pediatricians, and the aim of this study was to review the clinical signs and symptoms associated with developmental abnormalities of the genitourinary tract. DATA SOURCES: Based on the description of a symbolic clinical case, the authors conducted a non-systematic review of medical literature. DATA SYNTHESIS: The results suggest that the following data should be used as a warning for early diagnosis of affected children: (a) combined urinary tract abnormalities (chromosomal abnormalities; sequence of malformations [VACTERLand Prune-Belly]; and musculoskeletal, digestive tract, heart, and nervous system malformations); (b) previous history (congenital anomalies of the kidney and urinary tract [CAKUT] in the family, low birth weight, and oligoamnios); (c) clinical signs (polyuria/nocturia, urinary tract infection, systemic arterial hypertension, failure to thrive, weak urinary stream, difficulty to start urination, distended bladder, non-monosymptomatic enuresis, urinary/urge incontinence, and bowel and bladder dysfunction); and (d) pre- and postnatal ultrasonographic alterations (increased anteroposterior diameter of the renal pelvis, mainly in the third trimester of pregnancy; single kidney; hydronephrosis associated with other abnormalities; and hydronephrosis with parenchymal involvement in the post-neonatal assessment). CONCLUSION: The suggestions shown here can help the pediatrician to establish clinical hypotheses for the early diagnosis of developmental abnormalities of the genitourinary tract without resorting to expensive and invasive procedures.

Serum Endocan Levels Associated with Hypertension and Loss of Renal Function in Pediatric Patients after Two Years from Renal Transplant.

Endocan is an important biomarker of inflammation and endothelial dysfunction that increases in association with several chronic diseases. Few published data have described the role of endocan in pediatric renal transplant (RT) patients. We evaluated the endocan concentrations in 62 children who underwent renal transplantation and assessed their relationships with the patients' blood pressure and loss of renal function. The endocan levels were significantly elevated in the pediatric RT patients who had hypertension and a loss of renal function. We determined positive correlations between the endocan concentrations and the hemodynamic variables (systolic blood pressure: r = 0.416; P = 0.001; pulse pressure: r = 0.412; P = 0.003). The endocan levels were inversely correlated with the estimated glomerular filtration rate (r = -0.388; P = 0.003). An endocan cutoff concentration of 7.0 ng/mL identified pediatric RT patients who had hypertension and a loss of renal function with 100% sensitivity and 75% specificity. In conclusion, the endocan concentrations were significantly elevated in pediatric RT patients who had both hypertension and a loss of renal function. The correlations between the endocan levels and the hemodynamic variables and the markers of renal function strengthen the hypothesis that it is an important marker of cardiorenal risk.

Inequality in pediatric kidney transplantation in Brazil.

BACKGROUND: The aim of this study was to describe the access and factors associated with kidney transplantation for children in different regions of Brazil. METHODS: We analyzed a cohort of 1211 children enrolled on the transplant list from January 2011 to December of 2013. We fitted regression models to investigate factors associated with: (a) undergoing kidney transplantation from a deceased donor, and (b) being removed from the waiting list. RESULTS: The incidence of transplantation was uneven across regions, with the lowest rate at 0.4 per million age-related population (pmarp) in the Midwest and the highest incidence rate of 8.3 cases pmarp in the South. Children from the North and the Midwest regions had a 3-4 times lower probability of undergoing a deceased donor transplant (p < 0.05). Apart from the geographic region, age of recipients and GDP influenced the outcome. The likelihood of undergoing transplantation was very low in the youngest children in the North and Midwest. The number of transplant centers was not associated with either outcome. CONCLUSIONS: Factors of inequality in transplantation in Brazil are of macroeconomic origin, but there is room to reduce inequalities. Training existing transplant center professionals in the care of children could diminish the discrepancies.

Increased plasma selenium is associated with better outcomes in children with systemic inflammation.

OBJECTIVE: The aim of this study was to assess the effects of changes in plasma selenium on the outcome of critically ill children. METHODS: Plasma selenium was prospectively measured in 99 children with acute systemic inflammation. The exposure variables were selenium level on admission and on day 5 of stay in the intensive care unit (ICU) and the difference in selenium concentrations between day 5 post-admission and the ICU admission (delta selenium). Selenium was given only as part of enteral diets. Age, malnutrition, red cell glutathione peroxidase-1 activity, serum C-reactive protein, Pediatric Index of Mortality 2, and Pediatric Logistic Organ Dysfunction scores were analyzed as covariates. The outcome variables were ventilator-free days, ICU-free days, and 28-d mortality. RESULTS: Plasma selenium concentrations increased from admission (median 23.4 µg/L, interquartile range 12.0-30.8) to day 5 (median 25.1 µg/L, interquartile range 16.0-39.0; P = 0.018). After adjustment for confounding factors, a delta selenium increase of 10 µg/L was associated with reductions in ventilator days (1.3 d; 95% confidence interval [CI], 0.2-2.3; P = 0.017) and ICU days (1.4 d; 95% CI, 0.5-2.3; P < 0.01). Delta selenium >0 was associated with decreased 28-d mortality on a univariate model (odds ratio, 0.67; 95% CI, 0.46-0.97; P = 0.036). The mean daily selenium intake (6.82 µg; range 0-48.66 µg) was correlated with the increase in selenium concentrations on day 5. CONCLUSIONS: An increase in plasma selenium is independently associated with shorter times of ventilation and ICU stay in children with systemic inflammation. These findings raise the hypothesis that selenium supplementation could be beneficial in children with critical illnesses.

Growth of children with end-stage renal disease undergoing daily hemodialysis.

BACKGROUND: The aim of this report is to describe the effect of daily hemodialysis on the growth of children with end-stage renal disease (ESRD). METHODS: We performed a prospective, observational study on 24 children with ESRD undergoing daily hemodialysis (DHD). The control group comprised 26 children on concurrent conventional hemodialysis (CHD), and the follow-up for both groups was 9.3 ± 3.0 months. No patient received growth hormone (GH) therapy. RESULTS: At the onset of the study, the height-for-age Z-score was -2.12 ± 1.54 in the CHD group and -2.84 ± 2.27 in the DHD group (p = 0.313). Assuming an increase of 0.5 standard deviation scores (SDS) of the height-for-age parameter as an improvement of growth, there were 33 % of patients in the DHD group and 8 % in the CHD group (p = 0.035). The cumulative probability of gain in height for age at 12 months was 40 % in the DHD group versus 15 % in the CHD group (p = 0.047). Also, 98 % of patients in the DHD group had an adequate total caloric intake, whereas 38 % in the CHD group reached this goal (p < 0.001). No patient left the study due to intensification of the dialysis modality. CONCLUSIONS: Our data show that the DHD favored a 0.5 SDS height gain in a third of patients without GH treatment. Dialysis intensification was not a cause for treatment dropouts, and DHD should be considered as a treatment for selected cases, especially small children.

Does graft mass impact on pediatric kidney transplant outcomes?

BACKGROUND: The aim of this study is to assess the evolution of renal size and function in pediatric transplant patients according to the graft mass/recipient size ratio. METHODS: Fifty pediatric renal transplant recipients were followed over 2 years. Grafts were weighed, and three different graft mass/m(2) ratios were determined: (1) low graft mass (58 g/m(2), range 31-57 g/m(2)), (2) median (142 g/m(2), range 59-141 g/m(2)) and high (267 g/m(2), range 143-353 g/m(2)). Patients underwent repeated ultrasound Doppler scans and repeated measurements of estimated glomerular filtration rate (eGFR; 1 week and 1, 6, 12 and 24 months), urinary retinol-binding protein (RBP) and proteinuria (1 week and 6, 12 and 24 months). RESULTS: The volume of renal tissue increased by 12 ± 5.6 cm(3) at 24 months (p = 0.035) in the low graft mass and decreased by -14 ± 7 cm(3) (p = 0.046) in the high graft mass. The eGFR increased when either low (30 ± 5 ml/min/1.73 m(2), p < 0.001) or median (19 ± 4 ml/min/1.73 m(2), p < 0.001) graft mass was transplanted but remained stable when high graft mass was transplanted. The resistive index (RI) presented a significant decrease throughout early follow-up in the transplants involving low and median graft mass, whereas a slight rise was observed in those involving high graft mass. A significant difference was apparent 6 months post-transplant. Transplants of low and median graft mass were associated with an initial higher urinary RBP. No significant differences in proteinuria were detected. CONCLUSIONS: Small kidneys undergo increases in volume and function without escalation of either proteinuria or urinary RBP, characterizing an adequate adaptation to the recipient. Children receiving larger kidneys present a reduction in volume, stable GFR and higher RI at 6 months.

Ionized hypocalcemia is an early event and is associated with organ dysfunction in children admitted to the intensive care unit.

PURPOSE: The purpose was to determine the frequency and risk factors of ionized hypocalcemia and to evaluate this disturbance as a predictor of mortality in a pediatric intensive care unit (ICU). MATERIALS AND METHODS: In a prospective cohort study, 337 children admitted consecutively to an ICU were monitored regarding serum ionized calcium concentrations during the first 10 days of admission. The following variables were analyzed as independent of hypocalcemia: age; malnutrition; sepsis; Pediatric Index of Mortality 2; first 3 days organ dysfunction score (Pediatric Logistic Organ Dysfunction); and use of steroids, furosemide, and anticonvulsants. Hypocalcemia was defined as a serum ionized calcium concentration less than 1.15 mmol/L. RESULTS: The rate of hypocalcemia was 77.15%. In a multivariate model, higher Pediatric Logistic Organ Dysfunction scores during the first 3 days of ICU stay were independently associated with hypocalcemia (odds ratio, 2.24; 95% confidence interval, 1.23-4.07; P=.008). Medications associated with hypocalcemia were furosemide (dose≥2 mg/[kg d]) and methylprednisolone (dose≥2 mg/[kg d]). No significant association was found between hypocalcemia and 10-day mortality. CONCLUSIONS: Ionized hypocalcemia is common during the ICU stay, particularly in the first 3 days of admission. This disturbance was not found to be a predictor of mortality, but it is independently associated with more severe organ dysfunction.

What are the factors that influence the attainment of satisfactory energy intake in pediatric intensive care unit patients receiving enteral or parenteral nutrition?

OBJECTIVE: Children admitted to the intensive care unit (ICU) are at risk of inadequate energy intake. Although studies have identified factors contributing to an inadequate energy supply in critically ill children, they did not take into consideration the length of time during which patients received their estimated energy requirements after having achieved a satisfactory energy intake. This study aimed to identify factors associated with the non-attainment of estimated energy requirements and consider the time this energy intake is maintained. METHODS: This was a prospective study involving 207 children hospitalized in the ICU who were receiving enteral and/or parenteral nutrition. The outcome variable studied was whether 90% of the estimated basal metabolic rate was maintained for at least half of the ICU stay (satisfactory energy intake). The exposure variables for outcome were gender, age, diagnosis, use of vasopressors, malnutrition, route of nutritional support, and Pediatric Index of Mortality and Pediatric Logistic Organ Dysfunction scores. RESULTS: Satisfactory energy intake was attained by 20.8% of the patients, within a mean time of 5.07 ± 2.48 d. In a multivariable analysis, a diagnosis of heart disease (odds ratio 3.62, 95% confidence interval 1.03-12.68, P = 0.045) increased the risk of insufficient energy intake, whereas malnutrition (odds ratio 0.43, 95% confidence interval 0.20-0.92, P = 0.030) and the use of parenteral nutrition (odds ratio 0.34, 95% confidence interval 0.15-0.77, P = 0.001) were protective factors against this outcome. CONCLUSION: A satisfactory energy intake was reached by a small proportion of patients during their ICU stay. Heart disease was an independent risk factor for the non-attainment of satisfactory energy intake, whereas malnutrition and the use of parenteral nutrition were protective factors against this outcome.

Prevalence, risk factors, and consequences of overweight in children and adolescents who underwent renal transplantation--short- and medium-term analysis.

UNLABELLED: To determine the prevalence and risk factors for (i) overweight/obesity and (ii) weight gain six months after transplantation and to study the effect of weight excess on graft function and survival. We performed a retrospective study of kidney transplanted children. ENDPOINTS: (i) prevalence of overweight/obesity at sixth month, (ii) gaining 1.0 BMI SDS from one to six months. To study the effects of weight excess, graft function and survival at 36 months were the endpoints. The study included 197 individuals. At sixth month, 57/197 (29%) presented overweight/obesity, and the factors associated to this outcome were: (i) age at transplantation (OR = 3.04) and (ii) overweight/obesity in the first month (OR = 22.16). Groups presented no difference on graft function and survival at 36 months. From one to six months, 90/197 (46%) patients gained >1.0 BMI SDS. This outcome was associated with (i) female sex (OR = 2.50), (ii) steroids' pulses (OR = 2.98), (iii) steroids exposure (OR = 1.04), and (iv) living donor (OR = 2.69). The group that gained BMI presented a lower 36 months graft survival (86% vs. 98%, p < 0.001). Weight excess and gain after transplantation are frequent, particularly in younger female recipients and in those receiving high steroids exposure. The lower graft survival in patients with rapid weight gain deserves investigation.