Arteriovenous fistula as a complication of renal biopsy.

BACKGROUND: We evaluated the incidence and history of arteriovenous fistula (AVF) after kidney biopsy and assessed the use of superselective embolisation for treatment. METHODS: Case report of a 10-year-old boy with nephrotic syndrome. Renal biopsy (RB) in this patient was complicated with AVF. Immediately after RB was undertaken, microscopic haematuria was observed, within 48 hours after the biopsy life-threatening haematuria due to pseudoaneurysm started. Renal angiography was carried out, which demonstrated a hyperthrophic aberrant artery in the region of the bottom pole of the left kidney, from which blood was instantaneously flowing through a high-flow arteriovenous fistula (AVF). RESULTS: Embolization was carried out using small platinum coils (MWCE-18S-3/2, -18S-4/2, -18S-5/2TORNADO Embolization Microcoil) and the tissue adhesive Histoacryl. CONCLUSIONS: The technique of superselective embolisation using coaxial catheter is a safe method in the treatment of post biopsy AVFs and pseudoaneurysm (Fig. 3, Ref. 6).

[Consolidation of therapy of acute myeloid leukemia with the AML-BFM 93 protocol in children in the Czech Republic]. / Sjednocení lécby detí s akutní myeloidní leukémií v Ceské republice podle protokolu AML-BFM 93.

BACKGROUND: Acute myeloid leukemia (AML) in children is rare. Although more resistant to chemotherapy than acute lymphoblastic leukemia, its responsiveness and survival rates have considerably improved during the last 15 years by virtue of intensification of chemotherapy and due to the better supportive care. Relapses still remain the main cause of treatment failure. Management of children with AML was unified in the Czech Republic in 1993 according to AML-BFM 93 Study protocol. METHODS AND RESULTS: Treatment results were evaluated in 61 patients, of whom 45 (73.8%) achieved complete remission. Five-year event-free-survival (EFS) was found in 42.3%, and overall survival was 45.3%. Prognosis of the standard-risk patients was significantly better than in the high-risk group (EFS 62.5% vs. 29.7%, p = 0.03). The most important prognostic factor was the early treatment response. Compared to chemotherapy, allogeneic stem-cell transplantation did not significantly improve the outcome of high-risk patients. CONCLUSIONS: Treatment results of children with AML in the Czech Republic are comparable to those achieved by leading leukemia study groups in the world. The aim of the next study is to increase the complete-remission rate by reducing early deaths.

[Improved results in children with acute lymphoblastic leukemia treated with the ALL-BFM 90 protocol in the Czech Republic]. / Zlepsení výsledku lécby detí s akutní lymfoblastickou leukémií podle protokolu ALL-BFM 90 v Ceské republice.

BACKGROUND: Prognosis of children with acute lymphoblastic leukaemia (ALL)--the most common cancer in childhood, has improved remarkably over the last 40 years. The authors report the treatment outcome in children with ALL cured according to ALL-BFM 90 Study protocol in the Czech Republic during the first half of nineties. METHODS AND RESULTS: Children aged 0-18 years were included into the study in 10 centers between 1990 to 1996. Patients were classified into standard-risk (SR), medium-risk (MR) and high-risk (HR) group according to initial leukaemic burden, early treatment response, and genotype of leukaemia. Duration of the chemotherapy was two years. Treatment results were evaluated in 352 children. With a median follow-up of 7.3 years, event-free-survival (EFS) was 71.3% and overall survival 76.4%. EFS was 80.3%, 74% and 28.2% in SR, MR and HR group, respectively. Relapse was diagnosed in 17.8% of the patients. CONCLUSIONS: The treatment outcome of children with ALL improved significantly (p = 0.0045) compared to the previous study ALL-BFM 83 (EFS 62%). These results are comparable to those achieved by leading leukaemia study groups in the world.

The analysis of the risks for the development of tumour lysis syndrome in children.

BACKGROUND: Acute renal failure (ARF) during the course of cytostatic therapy is a serious complication. ARF can be isolated or became as component of tumour lysis syndrome (TLS). TLS comprises a number of metabolic abnormalities (hyperuricemia, hyperphosphatemia, hyperkalemia, azotemia and hypocalcemia) which are associated with lymphoproliferative malignancies following spontaneous or chemotherapy-induced cytolysis. There exist probably no clear prediction for the development of TLS that could enable early detection of manifestation of this severe condition. SUBJECTIVE: Conventional management with aggressive hydration, alkalization of the urine, administration of allopurinol, and the slow introduction of chemotherapy is often unable to prevent metabolic instability and ARF. Recent studies define a subgroup of patients at higher risk of renal failure during induction chemotherapy. ARF was encountered during initial therapy of patients with a lactate dehydrogenase (LDH) index greater than 3.3. METHODS AND MATERIAL: A retrospective analysis of 10 children (3 girls, 7 boys, average age 9.7 years) with LDII index greater than 3.3 has been done. All children were treated for lymphoproliferative malignancy with conventional preventive measures. RESULTS: Three children needed haemodialysis--2 boys had fully expressed TLS with ARF shortly after starting chemotherapy, in 1 boy the dialysis was indicated because of extreme hyperuricemia and high creatinine level presented before chemotherapy. We consider that LDH index is not specific criterium for prediction of TLS. In conclusion, our cases demonstrate the pathophysiologic spectrum of ARF in TLS between hyperuricemia and hyperphosphatemia. CONCLUSION: The LDH index, urine output, and hyperphosphatemia could be used to identify those paediatric patients who would benefit from the prospective use some of extracorporeal elimination methods. Further investigation of this techniques in a larger number of patients is warranted. (Tab. 5, Ref. 12.)

[Pathology of the spleen in children--current possibilities of surgical treatment]. / Patologie detské sleziny--soucasné moznosti chirurgického resení.

In the submitted paper the authors review the contemporary state of surgery of the spleen in child age. Surgical treatment is used most frequently in injuries of the spleen, in portal hypertension and in haematological diseases. In a group of patients during the last decade efforts to preserve the spleen are emphasized and experience is reported with the use of therapeutic procedures. The authors emphasize that splenectomy in children should be an exceptional operation.

[Laparoscopic surgery of the spleen in children]. / Laparoskopické výkony na slezine u detí.

Laparoscopic operations of the spleen, incl. splenectomy, are increasingly accepted worldwide. The most frequent indications for this type of surgical treatment are haematological diseases (some types of haemolytic anaemia, thrombocytopenia, myeloproliferative syndrome). Another indication for surgery is hypersplenism from other causes such as vascular anomalies or isolated thrombosis of the lienal vein. The reason for urgent or planned laparoscopy may be also traumatic damage of the spleen (haemorrhage, pseudocysts). In the submitted work the authors present their experience with 21 patients where a laparoscopic operation of the spleen was performed. Of 21 children four were laparoscopically operated on account of a mesothelial cyst or posttraumatic pseudocyst of the spleen (ratio 1:3). In another 15 children laparoscopoc splenectomy was performed for haematological reasons (11 x spherocytosis, 3 x idiopathic thrombocytopenic purpura, 1 x autoimmune haemolytic anaemia). Twice the operation was indicated on account of isolated thrombosis of the lienal vein. In three instances a concurrently, also laparoscopic cholecystectomy was performed and in two liver biopsy. On operation 3-5 troacars were used and the patient was placed in a supine position. In no instance preoperative embolization of the lienal arteries was performed. On treatment of cystic structures of the spleen the authors made in three instances total resection of a cyst--in the upper pole of the spleen, in case of a central localization, only 2/3 resection and fixation of the omentum. In resections recently coagulation and Argon spraying was used. The spleen was extracted by morcellation in a plastic bag or via a 5 cm left-sided subcostal incision (2x). The median size of the spleen was 14.4 cm (10-20 cm), of cystic formations 7.25 cm (6-8 cm). The mean period of operation in splenectomy was 146 minutes. In two patients a blood transfusion was necessary (1x splenectomy, 1x resection of the lower third of the spleen). As to complications the authors recorded once major haemorrhage after splenectomy--resolved by the use of Endo GIA stapler. Conversion was not necessary in any of the operations. The mean period of hospitalization was 6 days.

Is it possible to influence the mortality in children with hemolytic uremic syndrome?

THE CURRENT STATE: Hemolytic uremic syndrome (HUS) is the most frequent cause of acute renal failure in children. In our geographic conditions D(+)HUS prevails, in its etiology E. coli O157:H7 is represented most. In the course of HUS there can occur extrarenal damage to some organs, the manifestation of multiple organ failure is then possible. Delayed diagnosis of HUS, its complicated course and therapeutical strategy influence greatly the mortality rate of affected children. SUBJECTIVE: The optimal therapeutical procedure was elaborated on the base of evaluating the causes of death in children with HUS, and, simultaneously, there were revealed further reserves that can decrease the mortality rate. METHODS AND MATERIAL: A retrospective analysis of mortality within 1982-2000 was carried out in one of three centres dealing with the therapy for HUS in children in the Czech Republic. The total number of HUS children was 69 (40 girls, 29 boys, mean age 4.5 years). 9 patients out of the analyzed group died. RESULTS: Out of 9 children (4 girls, 5 boys) died, D(+)HUS was present in 7 (77.8%, 4 girls, 3 boys, mean age 2.1 years), D(-)HUS occurred in 2 subjects (22.2%, boys, mean age 7.5 years). Dialysis therapy was needed in all 9 children (peritoneal dialysis and/or hemodialysis). The mortality rate in our group of children was 13%. An autopsy carried out in dead children showed dominant severe affection of kidneys/brain/heart. CONCLUSION: In spite of marked decrease in the number of HUS children died particularly in developed countries, permanent attention must be paid to this disease. Besides early diagnosis, corresponding therapy is necessary. That should be performed at a specialized centre. The elaborated algorithm can be used in the therapy for HUS. This is one of the ways for further decrease of both mortality and chronic morbidity in children suffering from HUS. (Tab. 3, Fig. 1, Ref. 15.).

Oral rehydration in the therapy of simple diarrhea in infants and toddlers.

Acute diarrhea in infants and toddlers is frequent. Especially severe dehydration increases the risk of mortality in these children. In the therapy for uncomplicated diarrhea (dehydration no more than 9% of body weight loss) it is possible to use oral rehydration solutions (ORS). They are prepared easily, applied immediately, and the composition is also optimal for the body fluids of patients. ORS may be used in general pediatric practice but also during the treatment in hospital. This short report brings new aspects and practical considerations for the use of ORS by the most disadvantaged populations, as well as the need for public health.

Late effects of anticancer therapy on kidney function in children with acute lymphoblastic leukemia.

THE CURRENT STATE: Children with curable cancer are potentially at risk of long-term renal sequelae. The nephrotoxicity is considered dose related and includes a variable reduction of glomerular filtration rate along with tubular dysfunction. SUBJECTIVE: The aims of the present study were: to analyse kidney damage as well as the clinical course in children treated for ALL, to determine what type of nephrotoxic damage is most frequent in relation with the used treatment, to determine possible risks of acute and chronic nephropathy of anticancer therapy, to standardise evaluation of kidney function in children after their complex antitumourous treatment has finished. METHODS AND MATERIAL: We examined a group of 36 children (21 boys, 15 girls, average age at diagnosis of ALL 6.9 years)) treated for ALL using the therapeutical protocol ALL BFM 90. The average period after the treatment had finished was 48 month. The following parameters were examined: urinalysis and urine sediment, clearance of creatinine, tubular resorption, ultrasound of kidneys, 24 hrs proteinuria (PU) and urine concentration of albumine, transferine, alpha-1-microglobuline and Tamm-Horsfall protein. Concentration function of kidneys was examined by test with DDAPV. RESULTS: After finish of cytostatic therapy had 19 patients (52.8%) PU. Glomerular PU was found in 3 children (15.8%), in 3 children (15.8%) was found mixed PU and 13 children (68.4%) had tubular PU. Reduction of GFR had 5 patients (13.9%) and 19 patients (52.8%) had reduction of DDAPV test. CONCLUSION: Sensitive laboratory analysis of proteinuria is required for timely detection of the most frequent type of kidney damage in the course of treatment with cytostatics but also other concurrently administered drugs. Thus we can reliably detect mainly patients with glomerular/mixed proteinuria who are potentially imperilled by the risk of the development of chronic renal failure. If there is higher level of glomerular/mixed proteinuria even after the treatment has finished, the patients have to undergo another nephrological monitoring. (Tab. 3, Ref. 20.)

Gastric carcinoma in a 9-year-old boy.

Gastric carcinoma is an extremely rare cancer in children. A case is presented of a 9-year-old boy admitted to The University Hospital Brno with a 4-month history of abdominal pain, anorexia, weight loss, nausea, and vomiting. Several of his family members died from or have been treated for cancer. Barium meal examination performed 2 months prior to admission was nondiagnostic. When gastroendoscopy, laparoscopy, and abdominal computer tomography scan were performed, the diagnosis of adenocarcinoma of the stomach was established. The patient died 10 days after admission because of rapid cancer spread. Miliary metastases of the peritoneum, mesenterium, omentum, liver, bowels, lungs, heart, bone marrow, and skin were found. No penetration through the hematoencephalic barrier was noticed.

[Diagnosis of acute pyelonephritis in childhood: comparison of ultrasonographic examination and renal scintigraphy using 99mTc DMSA]. / Diagnostika akutní pyelonefritidy v detském veku: srovnání ultrasonografického vysetrení a scintigrafie ledvin pomocí 99mTc DMSA.

THE CURRENT STATE: Infections of the urinary tract are a frequent paediatric problem. Their treatment requires to assess the localisation of infection within the uropoetic tract. Especially the acute pyelonephritis (AP) can lead to irreversible changes within the renal parenchyma and alteration of renal functions. Some imaging examinations can help in the assessment of the diagnosis of AP and contribute to appropriate therapy. SUBJECTIVE: The analysis of results gained from imaging examinations in children with AP was based on the comparison of used techniques and the assessment of their exploitation for the diagnosis of AP. METHODS AND MATERIAL: 38 children (17 girls and 21 boys at average age of 11.6 years) with clinical criteria of AP were subdued to ultrasonographic examination with B record (US-B) and ultrasonographic examination with energetic Doppler (US-D). Both methods were compared with the findings gained by use of renal scintigraphy 99mTc DMSA. RESULTS: The positive finding of AP was proved in 36 children (94.7%). The results of US-B proved AP in 14 children (36.8%) of the whole group of patients, i.e. in 38.8% with positive DMSA finding. US-D changes indicated AP in 15 children (39.4%) of the whole group, i.e. in 41.6% with positive DMSA finding. The sensitivity of both methods US-B and US-D appear to be low for the verification of changes in renal parenchyma in AP. CONCLUSION: Despite its advantages and availability, the gain from ultrasonographic examination in children suffering from AP is small. Clinical and laboratory criteria are fully sufficient for AP verification in common clinical practice. DMSA scintigraphy is a method of choice in complicated cases of AP. (Tab. 1, Ref. 17.)