Are we late for the diagnosis of acute kidney injury in the intensive care units in pediatric patients? A preliminary, retrospective observational study among 66 patients.

BACKGROUND: The purposes of this study were to emphasize the importance of Risk, Injury, Failure, Loss, and End-Stage (RIFLE) classification in early diagnose and prognosis of acute kidney injury (AKI), and to evaluate the practicability of the RIFLE criteria in intensive care units. METHODS: Sixty-six patients applied acute peritoneal dialysis were included into the study. Patients having acute peritoneal dialysis within the first 24 hours of intensive care unit admission were named group 1, between 24-48 hours group 2, and those who had acute peritoneal dialysis 48 hours or more after admission to the intensive care unit were named group 3. Retrospectively, we evaluated patients by RIFLE criteria at the consultation time, and patients who had been just in AKI were called late referral patients. The mean interval time between the onset of AKI and the consultation time was defined as delay time in late referral patients. RESULTS: There were 20 patients in group 1, 15 were in group 2 and 31 in group 3. In total there were 18/66 patients in risk, 13/66 in injury while 35/66 in failure. There was statistically difference between delay times of in risk and failure class in group 3 (P<0.05). Also delayed patient numbers of both risk and failure class were found statistically highly significant (P<0.001). CONCLUSIONS: Most of the patients were in failure class at the time of consultation. We guess that if they would have been diagnosed earlier, prognosis might have been better. Therefore early diagnosis of AKI with RIFLE criteria and early initiation of acute peritoneal dialysis would probably improve prognosis.

Impact of peritoneal transport characteristics on cardiac function in paediatric peritoneal dialysis patients: a Turkish Pediatric Peritoneal Dialysis Study Group (TUPEPD) report.

BACKGROUND: The peritoneal equilibration test (PET) is recommended in paediatric peritoneal dialysis (PD) patients to assist prescription management. Despite contradictory reports, high transporter status is associated with reduced survival rate in adults. Since cardiac disease is one of the main causes of mortality in paediatric PD patients, we aimed to evaluate whether transport features have any effect on biochemical data and cardiac function in this group. METHODS: One hundred and ten PD patients (13 +/- 5 years, PD vintage: 31 +/- 27 months) were enrolled into the study. Four-hour dialysate/plasma creatinine ratio was used for differentiating PET groups. Thirty-eight patients were high transporters, 29 were high-average transporters and 43 were low-average/low transporters. Echocardiography was performed in all subjects. RESULTS: Age, PD vintage, dialysate glucose concentration, ultrafiltration volume, urine volume and blood pressure levels were similar in all PET groups. No biochemical or echocardiographic data (ejection fraction, fractional shortening, left ventricular mass index, myocardial performance index, power Doppler E/tissue Doppler E ratio reflecting diastolic function) were different among PET groups except lower albumin (P = 0.025) levels in high transporters and higher high-sensitivity C-reactive protein (P = 0.026) levels in high and high-average transporters compared to other transport groups. CONCLUSIONS: Cardiac structural and functional abnormalities are highly prevalent among paediatric PD patients. Transport rates did not have a significant effect on biochemical parameters or cardiac structural/functional parameters. It might be suggested that being a high transporter does not provide a disadvantage in terms of atherogenic tendency and cardiac disease in paediatric PD patients. Oligoanuria, anaemia and hypertension were independent predictors of cardiac disease.

Improved metabolic control and hepatic oxidative biomarkers with the periconception use of Helichrysum plicatum ssp. plicatum.

Our aim was to investigate the hypoglycaemic and antioxidant effects of the Helichrysum plicatum ssp. plicatum (HPsP) plant extract in the streptozotocin-induced type 1 diabetes rat model during pregnancy. Five groups (n = 8, each) were formed: (1) diabetic non-mated control, (2) non-diabetic mated control, (3) diabetic mated control, (4) diabetic non-mated treatment and (5) diabetic mated treatment. The HPsP extract was administered orally for 15 days (250 mg/kg body weight), beginning 3 days before mating. The extract led to decreased blood glucose, increased serum insulin, and decreased serum triglycerides in pregnant and non-pregnant diabetic animals. Liver thiobarbituric acid reactive substances (TBARS) and reduced glutathione (GSH) measurements in extract-treated diabetics were similar to non-diabetic pregnant controls, indicating probable reversal of increased lipid peroxidation in the liver. The mean pup number tended to increase (p = 0.06) with extract administration. In conclusion, the beneficial effects we encountered with the periconception use of the studied herbal extract warrant further investigation.

In vitro and in vivo evaluation of the effects of demineralized bone matrix or calcium sulfate addition to polycaprolactone-bioglass composites.

The objective of this study was to improve the efficacy of polycaprolactone/bioglass (PCL/BG) bone substitute using demineralized bone matrix (DBM) or calcium sulfate (CS) as a third component. Composite discs involving either DBM or CS were prepared by compression moulding. Bioactivity of discs was evaluated by energy dispersive X-ray spectroscopy (ESCA) and scanning electron microscopy (SEM) following simulated body fluid incubation. The closest Calcium/Phosphate ratio to that of hydroxyl carbonate apatite crystals was observed for PCL/ BG/DBM group (1.53) after 15 day incubation. Addition of fillers increased microhardness and compressive modulus of discs. However, after 4 and 6-week PBS incubations, PCL/BG/DBM discs showed significant decrease in modulus (from 266.23 to 54.04 and 33.45 MPa, respectively) in parallel with its highest water uptakes (36.3 and 34.7%). Discs preserved their integrity with only considerable weight loss (7.5-14.5%) in PCL/BG/DBM group. In vitro cytotoxicity tests showed that all discs were biocompatible.

Postnatal assessment of growth, nutrition, and urinary tract infections of infants with antenatally detected hydronephrosis.

The widespread utilization of prenatal ultrasonography and the detection of antenatal hydronephrosis (AH) have raised the importance of postnatal follow-up of these infants. In this study, we aimed to determine the importance of an early diagnosis for the treatment of urinary tract malformations (UTM) as well as the postnatal evaluation of growth and nutrition status and the frequency of urinary tract infection (UTI) in infants with AH. We evaluated 246 infants (183 boys, 63 girls) whose routine antenatal scans showed an anterior-posterior pelvic diameter (APPD) ≥5 mm. Of the 246 patients, 175 (71.1%) were found to be pathological and 71 were evaluated as normal after the follow-up period. The median follow-up periods of normal and abnormal cases were 45.7 and 43.4 months, respectively. All cases with or without UTM were evaluated in terms of UTI, scars on DMSA, growth [Height Z score (HZ), Weight Z score (WZ)] and nutrition [Weight height index (WHI)] status. The annual UTI frequency was higher in cases with UTM (1.32 ± 1.66 episode/year) than in cases without abnormality (0.27 ± 0.67 episode/year) (P < 0.001). The postnatal evaluation of growth and nutritional status in children with UTM (mean WHI, HZ, and WZ scores: 96.82 ± 10.21, 0.03 ± 0.54 and 0.04 ± 0.61, respectively) was found to be significantly worse than in cases without abnormality (102.25 ± 9.84, 0.14 ± 0.64 and 0.24 ± 0.76, respectively), (P < 0.05). In abnormal patients, the mean WHI, HZ, and WZ were significantly improved to 101.63 ± 9.75, 0.26 ± 1.07, and 0.28 ± 0.98, respectively, and HZ or WZ scores were found to be similar when compared to normals. In conclusion, postnatal early management of infants with AH seems to prevent frequent UTIs and nutritional disturbances enabling normal growth.

Hematopoietic stem cell transplantation in a CD3 gamma-deficient infant with inflammatory bowel disease.

Partial or total CD3 chain expression defects including CD3 gamma, epsilon, delta, and zeta chain are among the autosomally inherited SCID presenting with T-B+NK+ phenotype with lymphopenia. The clinical findings are generally severe in all except for CD3 gamma deficiency. Here we present a 10-month-old CD3 gamma deficient boy with IBD. The patient had suffered from intractable diarrhea, recurrent pulmonary infections and oral moniliasis since two months of age. Following the first allogeneic HSCT from his HLA-identical (6/6) sister after a reduced intensity regimen, a second transplantation was performed five months later. On day +19 after second transplantation, the CD3 TCR alpha/beta chain expression increased to 66% with development of full donor chimerism (98.6%). A significant improvement in diarrhea, perianal lesions, and rectal fistula was observed suggesting an improvement in inflammatory bowel disease. The patient died at home on day +50 with a sudden respiratory failure secondary to an undetermined infection. The case was interesting being the first reported case with SCID and inflammatory bowel disease who responded very well to HSCT by full recovery of intractable diarrhea, failure to thrive, laboratory findings, and improvement of fistula formation.

Postnatal management of infants with antenatally detected hydronephrosis.

With the increasing use of antenatal sonography, fetal hydronephrosis has been reported more frequently. Because of the lack of consensus regarding treatment of these infants, the postnatal approach toward fetal renal pelvis enlargement remains controversial. The aim of this prospective study is to demonstrate the postnatal investigation, treatment, and outcome of infants with prenatally diagnosed hydronephrosis. Infants whose antenatal ultrasound scan showed a fetal renal pelvis of 5 mm or greater were investigated postnatally using ultrasound (US) and voiding cystourethrography. When indicated, isotope studies and intravenous urograms were also performed. We followed prospectively neonates with antenatally diagnosed hydronephrosis and recommended management guidelines on the basis of our findings. In 156 neonates (193 kidney units) that were found to have hydronephrosis, the average gestational age at which the diagnosis was made was 32.94+/-5.10 weeks. The mean duration of postnatal follow-up was 26.3+/-13.56 months (range 3-60 months). The mean APPD of the fetal renal pelvis was 10.35+/-3.24 mm (5-9 mm in 84 kidneys, 10-14 mm in 96 kidneys and > or =15 mm in 13 kidneys). Of the 193 kidney units, 145 units were found to be pathological. The most common detected underlying abnormalities were ureteropelvic junction obstruction (in 91 kidneys; 62.7%) and vesicoureteral reflux (in 24 kidneys; 16.6%). Postnatally, 23 (45%) of 51 patients whose first US was normal were diagnosed postnatally as having urinary tract abnormality. There was a negative correlation between APPD and the rate of spontaneous resolution and positive correlation between APPD and the rate of surgery (P<0.01). In conclusion, because it is not possible to determine an upper limit of normal for the antenatal renal pelvis, any baby with AH should not be considered clinically insignificant. Infants with antenatal renal pelvis measurements > or =5 mm should be investigated postnatally. A normal postnatal ultrasound scan does not preclude the presence of urinary tract abnormality.

Percutaneous nephrostomy in children: diagnostic and therapeutic importance.

The aim of this study was to evaluate the effectiveness and safety of percutaneous nephrostomy (PN) in terms of diagnostic and therapeutic approach in children with urological problems. PN was performed on 39 kidneys in 28 patients (12 girls, 16 boys) aged 4.5 months to 13 years (average 5.38+/-3.41 years) during the period from January 1996 to December 2003. Underlying abnormalities were ureteropelvic junction obstruction (UPJO) in 14 patients (17 kidneys), ureterovesical junction obstruction (UVJO) in six patients (eight kidneys), supravesical obstruction due to tumour or hydatid cyst or ureteral stone in three patients (five kidneys), and severe vesicoureteral reflux (VUR) with/without neurogenic bladder associated with pyonephrotic kidneys in five patients (nine kidneys). The duration of catheter insertion was between 2 and 160 days (average 80+/-65.01 days). The complications were haematuria (six cases), infection (five cases) and displacement of catheter (four cases). Radical surgical management was performed in 25 patients (33 kidneys): pyeloplasty in eight cases (ten kidneys), UVJO correction in six cases (eight kidneys), nephrectomy in five cases (five kidneys), ureteroneocystostomy in four cases (seven kidneys), hydatid cyst operation in one case (two kidneys) and stone extraction in one case (one kidney). PN is an easy, safe and efficient diagnostic and therapeutic procedure with few complications in childhood.

Chronic peritoneal dialysis in Turkish children: a multicenter study.

Chronic peritoneal dialysis (CPD) has been utilized in the treatment of children since 1989 in Turkey. The aims of this study were to summarize our experience with CPD in children and to establish a pediatric registry data system in Turkey. Standard questionnaires were sent to all pediatric CPD centers. 514 patients treated between 1989 and 2002 in 12 pediatric centers were enrolled in the study. Reflux nephropathy was the most common (18.1%) cause of renal failure. Mean age at dialysis initiation was 10.1+/-4.6 years. Mean duration of dialysis was 24.1+/-20.5 months. Continuous ambulatory peritoneal dialysis (CAPD) was the first CPD modality for 476 (92.6%) patients, 142 of whom switched to automated peritoneal dialysis (APD) during follow-up. Currently, 47.3% of the patients are still on CPD, 15.4% were transplanted, 13.2% switched to hemodialysis, 16.7% died. The patient and technique survivals were 90% and 95% at one year and 70% and 69% at five years, respectively. The survival was significantly shorter in the youngest age group (0-24 months) compared to those in older age groups (p=0.000). We herein report the first results of the TUPEPD study providing information on demographic data and survival of pediatric CPD patients. As opposed to clear recommendations in favor of APD, there is a clear preponderance of CAPD in our pediatric CPD population. That vesicoureteral reflux (VUR) is still the leading cause of renal failure is a distressing finding. Remarkably lower survival rates and transplantation ratios are as striking and distressing as the high incidence of VUR among the causes of ESRD. We conclude that we must make a great effort to achieve better results and to change these undesirable events.

Does endoluminal brushing eliminate the need for catheter removal in peritoneal dialysis patients with persistent peritonitis?

Recurrent and persistent peritonitis episodes are exhausting problems in children on chronic peritoneal dialysis (PD) and can lead to discontinuation of treatment. In the present report, we describe our clinical experience with endoluminal brushing (EB) in 3 pediatric patients with refractory peritonitis episodes maintained on chronic PD. The EB was performed on 4 occasions in 3 patients. Peritonitis resolved in 2 of the patients. The remaining patient required removal of the PD catheter. No adverse events have since been observed. Endoluminal brushing should be considered an option for the management of persistent peritonitis before catheter removal.

The role of nitric oxide in mediating nonadrenergic, noncholinergic relaxation in rat pulmonary artery.

Experiments were undertaken to investigate the existence of inhibitory nonadrenergic, noncholinergic (i-NANC) nerve activity by using in vitro functional and immunohistochemical techniques in rat main pulmonary arterial rings. Vessels precontracted with phenylephrine (3 microM) relaxed in response to electrical field stimulation (EFS) (50 V, 0.2 ms, 0.1-10 Hz for 5 s) in the presence of atropine (1 microM) and guanethidine (1 microM). Tetrodotoxin (0.3 microM) abolished this response, indicating that it is neuronal in origin. l-NAME (30 microM), methylene blue (10 microM), and removal of endothelium significantly reduced the EFS-induced relaxations. The inhibitory action of l-NAME was completely reversed by l-arginine (1 mM) but not by d-arginine (1 mM). Moreover l-arginine alone potentiated the magnitude of the relaxations elicited by EFS. On the other hand, immunohistochemical work clearly demonstrated the existence of neuronal nitric oxide synthase in the pulmonary artery vessel wall. All these results are consistent with the suggestion that nitric oxide is the likely mediator of this vasodilatation. However, the incomplete blockade of the responses by l-NAME gives evidence of an additional inhibitory NANC neurotransmitter(s) mediating the residual relaxation, which requires further experiments to clarify its nature.

Proximal bronchial extension with special reference to tumor localization in non-small cell lung cancer.

OBJECTIVE: Surgery is the optimal treatment in patients with non-small cell lung cancer (NSCLC) and tumor-negative bronchial resection margins should be maintained for a curative resection. The epidemiology of NSCLC, including the aspects of tumor localization, has been changing during the recent decades. The aim of this study was to evaluate microscopic proximal bronchial extension with special reference to the site of the tumor. METHODS: Surgical specimens of 70 NSCLC cases were examined histologically for proximal bronchial extension of the tumor. The entire bronchial tree with the tumor was extracted from the specimen and serially cut at a thickness of 5 mm in the transverse plane of the bronchus. Microscopic proximal extension of the tumor was classified as either endobronchial or peribronchial. RESULTS: Thirty-three (47.1%) tumors had central and 37 (52.9%) had peripheral localization. Among the central and peripheral tumors, 10 (30.3%) and seven (18.9%) had microscopic proximal extension, respectively. In total, the mean length of proximal extension was 10.94 +/- 7.07 mm. The mean length of extension for peripheral tumors was 15.71 +/- 8.38 mm, significantly greater than that of central tumors, which was 7.60 +/- 3.47 mm (P = 0.026). Peripheral tumors showed a significant peribronchial extension (P = 0.024). CONCLUSIONS: A greater percentage of central tumors show microscopic proximal bronchial extension, whereas the length of microscopic proximal bronchial extension is significantly greater in peripheral tumors. Peripheral tumors preferentially have a peribronchial extension pattern.

Collecting duct carcinoma.

Collecting duct carcinoma of the kidney is a rare variant of renal cell carcinoma. Hematuria is the most common presenting symptom. This tubulopapillary tumor arises from or differentiates forward to medullary collecting tubules. It is typically centered on the medulla of the kidney and extends into the cortex with a desmoplastic reaction. There are few reports documenting the clinical presentation and long-term prognosis. We describe a case of this uncommon tumor with clinical, histological and immunohistochemical features and review the literature.

Inducible nitric oxide synthase expression in benign prostatic hyperplasia, low- and high-grade prostatic intraepithelial neoplasia and prostatic carcinoma.

OBJECTIVE: To elucidate the incidence of inducible nitric oxide synthase (iNOS) expression in benign prostatic hyperplasia (BPH), low- and high-grade prostatic intraepithelial neoplasia (PIN) and prostatic carcinoma lesions, and to explore the role of iNOS in prostate tumorigenesis. MATERIALS AND METHODS: Immunoreactivity for iNOS was examined in 20 samples each of BPH, high-grade PIN, low-grade PIN and prostatic carcinoma. RESULTS: Positive iNOS immunostaining was detected in all samples from all patients; iNOS was detected in both basal epithelial cells and secretory cells of the glandular epithelium. High-grade PIN and prostatic carcinoma samples had more intense iNOS immunostaining than low-grade PIN and BPH samples. In all samples, smooth muscle cells showed weak or moderate iNOS immunoreactivity and endothelial cells showed moderate immunostaining. CONCLUSIONS: Nitric oxide generated by iNOS may be involved in prostate tumorigenesis and further studies with immunohistochemical and molecular biology are needed to determine the exact role of iNOS in the pathogenesis of prostatic carcinoma.

P53, bcl-2 and bax immunoreactivity as predictors of response and outcome after chemotherapy for metastatic germ cell testicular tumours.

OBJECTIVE: To evaluate the roles of p53, bcl-2 and bax as determinants of chemosensitivity in testicular cancers and to assess whether immunohistochemical expression of these proteins in testicular germ cell tumours (GCTs) could be used to predict the outcome in patients with metastatic testicular GCTs. PATIENTS AND METHODS: Immunoreactivity for p53, bcl-2 and bax were examined in primary testicular tumours from 24 patients with metastatic GCTs who were treated with bleomycin, etoposide and cisplatin chemotherapy. All immunostaining results were scored for the appropriate percentage of positive tumour cells and relative immunostaining intensity (score range 0-15) and compared with the response of the patients to chemotherapy. RESULTS: Overall, 20 (83%), 13 (54%) and 24 of the 24 GCTs showed > or = 1% immunoreactivity with p53, bcl-2 and bax, respectively. Only the bax immunostaining intensity and score had statistically higher mean values in the nonseminoma than in seminoma GCTs (P = 0.047 and P = 0.027, respectively). Only p53 immunostaining intensity, percentage of p53 immunopositive cells and p53 staining score were sig-nificantly different among the response groups. The median survival after chemotherapy was 30.5 months; however, taking the median values of the immunostaining scores as threshold values for the survival analysis, none of the three proteins were associated with significant differences in survival. CONCLUSIONS: The incidence of p53 and bax immuno-reactivity in testicular GCTs is higher than that of bcl-2 immunoreactivity. However, only p53 immuno-reactivity could be used to predict the response to chemotherapy. P53, bcl-2 and bax scores were not significant prognostic factors for survival after chemotherapy.

Association of nitric oxide production and apoptosis in a model of experimental nephropathy.

BACKGROUND: In recent studies increased amounts of nitric oxide (NO) and apoptosis have been implicated in various pathological conditions in the kidney. We have studied the role of NO and its association with apoptosis in an experimental model of nephrotic syndrome induced by a single injection of adriamycin (ADR). METHODS: The alteration in the NO pathway was assessed by measuring nitrite levels in serum/urine and by evaluating the changes in vascular reactivity of the isolated perfused rat kidney (IPRK) system. Rats were stratified into control groups and ADR-induced nephropathy groups. These two groups were then divided into: group 1, animals receiving saline; and group 2, animals receiving aminoguanidine (AG) which is a specific inhibitor of inducible-NO synthase. On day 21, rats were sacrificed after obtaining material for biochemical analysis. RESULTS: Histopathological examination of the kidneys of rats treated with ADR revealed focal areas of mesangial proliferation and mild tubulointerstitial inflammation. They also had significantly higher levels of proteinuria compared with control and treatment groups (P < 0.05). Urine nitrite levels were significantly increased in the ADR-nephropathy group (P < 0.05). In the IPRK phenylephrine and acetylcholine related responses were significantly impaired in the ADR-nephropathy group. Apoptosis was not detected in controls. However, in the ADR-nephropathy group, numerous apoptotic cells were identified in the tubulointerstitial areas. Double staining revealed numerous interstitial apoptotic cells to stain for ED1, a marker for monocytes/macrophages. Treatment with AG prevented the impairment of renal vascular bed responses and reduced both urine nitrite levels and apoptosis to control levels. CONCLUSION: We suggest that interactions between NO and apoptosis are important in the pathogenesis of the ADR-induced nephrosis.

Leiomyoma of the epididymis.

Tumours of the epididymis, both primary and secondary, whether benign or malignant are very rare. We report a case of leiomyoma of the epididymis and discuss the treatment of this tumour.