A practical primary care approach to hematuria in children.

Although hematuria is a common finding in the unselected population of children, the approach to evaluation is quite variable. Changes in the practice of primary care medicine in the United States mandate an approach to common office problems that is practical and realistic. This review addresses three areas: the current approach to evaluation of hematuria in children, a classification of children with hematuria into four distinct and easily identified clinical categories, and the development of an algorithm for application in the primary care setting. Each category is discussed relative to the more-common etiologies of hematuria, with recommendations for appropriate evaluation as well as suggestions of an appropriate referral to the nephrologist. An algorithm is proposed that provides a practical, systematic approach to the problem without the requirement for a specific diagnosis in every patient. The proposed classification and approach to the evaluation of children with hematuria should help simplify and clarify a potentially complex process.

Role of transplant induction therapy on recurrence rate of focal segmental glomerulosclerosis.

Individuals with focal segmental glomerulosclerosis (FSGS) are at risk for recurrence of disease following renal transplantation. The rate of recurrence has been estimated to range from 20% to 30%. The factors associated with an increased probability of recurrence are not known, although the rapidity of progression of disease, age at onset, and the presence of diffuse mesangial proliferation in the native kidney have all been implicated. We analyzed the data from 35 patients with FSGS who received 37 renal transplants at this institution between October 1968 and December 1997. Recurrence was diagnosed by the development of nephrotic-range proteinuria and a transplant biopsy compatible with the diagnosis. Sixteen recurrences were noted, with an overall recurrence rate of 43%. The risk of recurrence was associated with the use of antilymphocytic serum (ALS) for initial induction therapy; being 11% in those who received no induction therapy versus 53% in those who received ALS. Furthermore, in the latter group, the rate of recurrence was 88% in those who received antithymocyte globulin (ATGAM) versus 40% in those who received Minnesota antilymphocytic globulin. Factors such as race, sex, age at time of diagnosis, rapidity of progression to end-stage renal disease (ESRD), response to alkylating agents and/or cyclosporin therapy prior to ESRD, age at time of transplant, donor source, and triple or double immunosuppressive therapy did not appear to have an effect on the rate of recurrence. We conclude that induction therapy with ALS at time of transplantation increases the risk of recurrence of FSGS following renal transplantation.

IgA induced activation of human mesangial cells: independent of FcalphaR1 (CD 89).

BACKGROUND: IgA nephropathy (IgAN) is characterized by deposition of polymers of IgA1 in the mesangium, accumulation of mesangial matrix and mesangial cell proliferation. Activation of the mesangial cell by IgA, via an IgA receptor, may be an initiating event in the pathology of IgAN. METHODS: We examined the ability of radiolabeled, normal serum IgA1 to bind human mesangial cells (HMC). Activation of HMC by monomeric (mIgA1) and heat aggregated IgA1 (AIgA1) was compared by Northern analysis of c-jun expression. The expression of FcalphaR1 (CD89) mRNA on our cultured mesangial cells was also assessed by Northern analysis, reverse transcription-polymerase chain reaction (RT-PCR) and flow cytometry. RESULTS: 125I-mIgA1 and 125I-AIgA1 bound to HMC in a dose-dependent, saturable manner with similar affinities. There were 1.2 x 10(6) binding sites per cell, with an affinity constant of 2.3 x 10(6) M(-1). AIgA1 induced c-jun expression in a time and dose-dependent manner (2.4-fold above baseline after 60 min exposure to AIgA1 200 microg/ml) while mIgA1 had no effect on c-jun expression. No message for CD 89 was detectable in quiescent or AIgA1 stimulated HMC by Northern analysis or RT-PCR using several primer sequences based on the sequence of U937 FcalphaR cDNA. Flow cytometry on the mesangial cells, using My 43, a monoclonal antibody to FcalphaR1 confirmed that CD 89 was not present on the cell. CONCLUSION: These results demonstrate that HMC bind mIgA1 and AIgA1 with similar affinity. However, activation of HMC requires an aggregated form of IgA1. These processes are independent of FcalphaR1, suggesting the presence of a new IgA receptor on mesangial cells.

Effect of standardized approach to the care of the extremely low birthweight infant.

An extremely low birthweight (ELBW) protocol was developed at this regional neonatal intensive care unit. The focus was the standardization of care related to the implementation/maintenance of a humidified environment and attention to prevention of skin excoriation in the extremely low birthweight infant (< 1000 g). Steps toward successful implementation of the standardized approach required an interdisciplinary commitment, literature review of current practice methodologies, a definition of nursing and medical approach to these infants in the first days of life, and an evaluation of the practice change focusing on patient outcomes. A comparative review was completed that evaluated the change in patient outcomes of the extremely low birthweight infants relative to fluid and electrolyte status in the first five days of life after implementation of the protocol as compared to prior to implementation of the protocol.

Increased glomerular and urinary malondialdehyde in puromycin aminonucleoside-induced proteinuria in rats.

Puromycin aminonucleoside (PAN)-induced proteinuria in rats may be mediated by reactive oxygen metabolites (ROM), which are injurious to several cell components including membrane lipids. Increased malondialdehyde (MDA) production is indicative of lipid peroxidation. We examined if MDA content of glomeruli and its urinary excretion were increased in rats administered PAN. Of three groups of 8 Sprague-Dawley rats each, group 1 served a control, group 2 animals received a single intravenous injection of PAN (5 mg/100 g body weight) and group 3 animals PAN with intraperitoneal injections of dimethylthiourea (DMTU), a free radical scavenger of oxidants such as hydroxyl radicals, for 4 days. The rats were sacrificed on day 8 after PAN injection. Increasing proteinuria, starting on day 4, developed in animals in group 2 but not in the others. The glomerular MDA (nmol/mg protein) in group 2 animals was 2.93 +/- 1.91, significantly higher than 0.87 +/- 0.63 and 1.26 +/- 0.76 in groups 1 and 3, respectively. Urinary levels of MDA markedly increased in group 2 rats on day 3 and remained high thereafter, but no such increase occurred in the control animals and those administered PAN with DMTU; the latter was thus protective against PAN toxicity. Our observations support the view that ROM are involved in PAN-induced glomerular injury and that increased urinary MDA excretion can be a marker of ROM-mediated lipid peroxidation.

Prompt remission of post-renal transplant nephrotic syndrome with high-dose cyclosporine.

A 2.8-year-old girl with focal segmental glomerulosclerosis had recurrence of nephrotic syndrome within 3 days of renal transplantation and the serum creatinine increased. Renal biopsy showed cellular rejection and also complete effacement of the epithelial cell foot processes. The rejection responded to methylprednisolone therapy but massive proteinuria persisted. An increase in the dose of cyclosporine A to 14 mg/kg per day was followed by immediate remission of the proteinuria. One month later, a second renal biopsy showed only focal fusion of foot processes. She remains free of proteinuria 2 years later. We propose that the higher dose of cyclosporine caused remission of the nephrotic syndrome.

Cutaneous manifestations of acrodynia (pink disease).

A 14-month-old girl who presented with multiple systemic complaints was found to have gingivitis, peeling of her palms and soles, and a peculiar acral eruption. A diagnosis of acrodynia, or pink disease, was confirmed by elevated levels of mercury in the urine. The many cutaneous manifestations of this once common disease are discussed.