Bladder contractility index in posterior urethral valve: A new marker for early prediction of progression to renal failure.

INTRODUCTION: Posterior urethral valve (PUV) is the most common cause of pediatric end stage renal disease (ESRD), imposing a major health burden on medical community caregivers and adversely affecting the quality of life of patients. Chronic kidney disease (CKD) stage III or estimated GFR of <60 mL/min/1.73 m2 is known to be associated with more adverse renal, cardiovascular, and clinical outcomes. Thus, it is desirable to identify factors predicting the rapid and early progression of disease. In the present study, baseline characteristics and urodynamic study (UDS) parameters of boys with PUV are correlated with CKD progression to IIIB or more. AIMS AND OBJECTIVES: To study the correlation of bladder contractility index (BCI) with development of CKD stage IIIB (eGFR of <45 mL/min/1.73 m2) or more in boys with PUV. METHODOLOGY: Baseline characteristics and demographical variables of 270 boys with PUV who underwent valve fulguration at the hospital between 2000 and 2010 were recorded and certain UDS parameters in follow-up were noted such as bladder contractility index (BCI = PdetQmax + 5 Qmax), end filling pressure (EFP), compliance (ΔC), bladder outlet obstruction index (BOOI = Pdet Qmax - 2 Qmax), and bladder volume efficiency (BVE = Voided volume/total capacity). Fate of patients in follow-up was checked in December 2015. RESULTS: Mean follow-up period was 8.5 years (range 5-15) and median age of patients at the time of evaluation was 5.8 years. At the end of the study, 21.8% (59/270) of patients had progressed to CKD stage IIIB or more (primary end point). Cox regression analysis was applied to risk factors predicting development of CKD stage IIIB. In the multivariate model, bladder contractility index (BCI) (HR 0.8; p = 0.004), end filling pressure (EFP) (HR 2.1; p = 0.010), and compliance (ΔC) (p = 0.020) were significantly associated with the event (i.e. an eGFR of <45 mL/min/1.73 m2), whereas BOOI (p = 0.053) and bladder BVE (p = 0.267) were not. ROC cut-off level for BCI predicting the primary end point was 75 (AUC ± SE, 0.73 ± 0.03, sensitivity of 78.2%, and specificity of 62.5%). CONCLUSION: In a well performed UDS, BCI may be a useful tool for early detection of boys with PUV who are likely to progress to CKD stage IIIB or more.

Can baseline serum creatinine and e-GFR predict renal function outcome after augmentation cystoplasty in children?

ABSTRACT Objective To assess cut-off value of creatinine and glomerular filtration rate for augmentation cystoplasty (AC) in paediatric age-group. Materials and Methods Data of all paediatric-patients (<18 years) with small capacity bladder, in whom AC was advised between 2005-2015 were reviewed. All patients were divided in two-groups, AC-group and control-group (without AC). Creatinine and e-GFR were assessed at the time of surgery, at 6 months and at last follow-up. Renal function deterioration was defined as increase in creatinine by ≥25% from baseline value or new-onset stage-3 CKD or worsening of CKD stage with pre-operative-CKD stage-3. ROCs were plotted using creatinine and e-GFR for AC. Results A total of 94 patients with mean-age 8.9 years were included. The mean creatinine and e-GFR were 1.33mg/dL and 57.68mL/min respectively. Out of 94 patients, AC was performed in 45 patients and in the remaining 49 patients AC was not done (control-group), as they were not willing for the same. Baseline patient's characteristics were comparable in both Groups. 22 underwent gastro-cystoplasty (GC) and 25 underwent ileo-cystoplasty (IC). Decline in renal function was observed in 15 (33.3%) patients of AC-group and in 31 (63.3%) patients of control-group. Patients having creatinine ≥1.54mg/dL (P=0.004, sensitivity (S) 63.6% and specificity (s) 90.5%) at baseline and e-GFR ≤46mL/min (P=0.000, S=100% and s=85.7%) at the time of surgery had significantly increased probability of renal function deterioration on follow-up after AC. Conclusion e-GFR ≤46mL/min and creatinine ≥1.54mg/dL at time of surgery could serve as a predictor of renal function deterioration in AC in paediatric patients.

Can baseline serum creatinine and e-GFR predict renal function outcome after augmentation cystoplasty in children?

OBJECTIVE: To assess cut-off value of creatinine and glomerular filtration rate for augmentation cystoplasty (AC) in paediatric age-group. MATERIALS AND METHODS: Data of all paediatric-patients (<18 years) with small capacity bladder, in whom AC was advised between 2005-2015 were reviewed. All patients were divided in two-groups, AC-group and control-group (without AC). Creatinine and e-GFR were assessed at the time of surgery, at 6 months and at last follow-up. Renal function deterioration was defined as increase in creatinine by ≥25% from baseline value or new-onset stage-3 CKD or worsening of CKD stage with pre-operative-CKD stage-3. ROCs were plotted using creatinine and e-GFR for AC. RESULTS: A total of 94 patients with mean-age 8.9 years were included. The mean creatinine and e-GFR were 1.33mg/dL and 57.68mL/min respectively. Out of 94 patients, AC was performed in 45 patients and in the remaining 49 patients AC was not done (control-group), as they were not willing for the same. Baseline patient's characteristics were comparable in both Groups. 22 underwent gastro-cystoplasty (GC) and 25 underwent ileo-cystoplasty (IC). Decline in renal function was observed in 15 (33.3%) patients of AC-group and in 31 (63.3%) patients of control-group. Patients having creatinine ≥1.54mg/dL (P=0.004, sensitivity (S) 63.6% and specificity (s) 90.5%) at baseline and e-GFR ≤46mL/min (P=0.000, S=100% and s=85.7%) at the time of surgery had significantly increased probability of renal function deterioration on follow-up after AC. CONCLUSION: e-GFR ≤46mL/min and creatinine ≥1.54mg/dL at time of surgery could serve as a predictor of renal function deterioration in AC in paediatric patients.

Importance of lower pole nephrectomy during ureterocalicostomy.

Ureterocalicostomy is usually a salvage procedure for recurrent pelvi-ureteric junction (PUJ) stricture or upper ureteric injury. It requires meticulous dissection of the upper ureter, and lower pole nephrectomy is considered an essential step to achieve a wide funneled and dependent ureterocaliceal anastomosis. We, hereby, highlight the importance of guillotine lower pole nephrectomy through a case report of recurrent PUJ stricture managed with ureterocalicostomy that failed due to the omission of lower pole nephrectomy.

Multidimensional assessment of quality of life of children and problems of parents in Indian society after pediatric renal transplant: Beyond the conventional thoughts.

This study evaluated multidimensional QoL after renal transplant to find the physical, psychosocial, and economic issues after pediatric transplant. Sixty-two patients under the age of 18 at the time of assessment were asked to complete WHOQOL questionnaires. Assessment of behavioral, emotional status of child, problems of parents, and SEC of family were also performed. The beneficial effect of transplantation was observed across all domains of QoL (physical, psychological, social, environmental, and overall QoL). The greatest change was observed in QoL domains that dealt with overall satisfaction (81.28±15.76 vs 45.32±10.98; P<.0001). The domain dealing with environmental factors showed the least variation after transplantation (65.58±17.45 vs 51.34±17.81; P<.0001). Feelings of happiness and peer group socialization were reported in 81% and 69% of patients, respectively. There was no marital disharmony in 52% of families. However, SEC deteriorated in 16% of families and 59% of the families availed financial assistance. Sixty-nine percent of children had not attended school after one year of transplantation, but return to school after transplant was reduced to 8% at 5 years. Pre- and post-transplant social and psychological support may help these patients and their families adjust in society and have a positive outlook for their future.