Routine admission urinalysis examination in pediatric patients: a poor value.

The urinalysis has long been considered an important screening test for hospitalized children. The value of the admission urinalyses, required by hospital bylaws, was assessed for detecting urinary tract disease in children admitted to a day-care unit or impatient medical or surgical services during the months of June and November 1987. Of 2695 admissions, urinalyses were considered essential for diagnosis or therapy in 543 patients (excluded from analysis). In the remaining 2152 patients eligible for screening, urinalyses were obtained in 145 (30%) of day-care unit and 587 (35%) of inpatient admissions. The results of 149 (20%) of screening urinalyses were abnormal (23% abnormal in inpatient and 10% abnormal in day-care unit admissions). The numbers of urinalyses with abnormal results were similar in surgical and medical admissions and between the months of June and November. Pyuria (90 patients) and hematuria (66 patients) were the most common abnormalities in initial urinalyses. Follow-up urinalyses and other diagnostic studies were obtained in 38% of patients with abnormal admission urinalysis results. In subsequent urinalyses, 58% showed persistent abnormalities; however, most subsequent abnormal results were not pursued with additional tests. Urinary tract infections were diagnosed in 6 patients. No other additional diagnoses were determined. The cost of initial urinalyses and subsequent diagnostic studies in these 732 patients during the 2 months was $23,465. The cost per diagnosis of urinary infection was $3911. It is concluded that when hospital bylaws require routine urinalyses at the time of admission, this requirement is frequently ignored and, in addition, abnormal results are often unappreciated or not pursued.(ABSTRACT TRUNCATED AT 250 WORDS)

Integration of community pediatricians into an academic department.

A process of enhanced participation by community pediatricians in the programs and administration of an academic department is described. We realize that many departments incorporate volunteer faculty into their academic programs without creating a specific structure, such as our divisional classification. The customary paradigm of providing "ad hoc" opportunities and responsibilities for volunteer faculty is somewhat analogous to the traditional "quality assurance" model of management, which is responsive in nature and places the participants in a dependent relationship to the academic leadership. Creating academic division structure allows the volunteer faculty to initiate projects, create interdivisional work teams, and evaluate the results of their involvement and is more reflective of the new "continuous quality improvement" model. This system elevates the volunteer faculty into a partnership relationship with the academic faculty. The sense of ownership and opportunity for personal growth appear to be important drives for sustained community involvement. Although the benefits of our program appear promising, committed leadership within the academy and community will be required for long-term success. Re-analysis of the intramural dynamics and activities following systemic restructuring of the health care system will be of interest.

Digital subtraction angiography in the evaluation of renal vascular hypertension in children.

Twenty children were evaluated with digital subtraction angiography (DSA) for renal vascular hypertension. IV DSA from a basilic vein approach was performed in four patients and femoral vein approach in two patients. Intraarterial DSA was performed in 14 patients with suspected renal vascular hypertension. Renal vein renin samples were obtained from 17 patients. Two renal artery angioplasties were performed in association with intraarterial DSA. IV DSA was diagnostic in five of six patients with one false-negative result for fibromuscular dysplasia of the tertiary vessels. Intraarterial DSA images were diagnostic in 14 of 14 patients, and renal vein renin results correlated well with DSA results. In 11 patients, DSA was performed as an outpatient (hospital day-care unit) procedure. Of the 20 patients evaluated, 13 patients had abnormal DSA findings which included a hypoplastic but functioning kidney in three patients, distal small vessel abnormalities in five patients, unilateral or peripheral renal artery stenosis in four patients, and middle aortic syndrome in one patient. DSA with renal vein renin samples can be used as a diagnostic procedure for the evaluation of renal vascular hypertension in children as well as adult patients. In addition, it is a useful tool for therapeutic vascular procedures in children.

Hypertension associated with the Guillain-Barré syndrome.

Guillain-Barré syndrome (GBS) is frequently complicated by hypertension, which has been ascribed to sympathetic nervous system hyperactivity. We report the case of a child with GBS and hypertension that appeared to be related to increased renin-angiotensin activity. Urinary catecholamine excretion was normal. Propranolol therapy successfully controlled the hypertension. Evaluation of the renin-angiotensin system and catecholamine excretion is indicated in patients with GBS and hypertension.

Urinary excretion of calcium following an oral calcium loading test in healthy children.

The ratio of urinary calcium (UCa)/urinary creatinine (UCr) concentrations (mg/mg) during calcium loading has been used to diagnose hypercalciuric states in adults. The UCa/UCr ratios have been examined before and after an oral dose of calcium in 48 healthy children following five days of abstinence from dietary milk products. No differences in UCa/UCr ratios were observed between sexes, races, or age groups. UCa/UCr ratio before the calcium dose was 0.09 +/- 0.12 (mean +/- 2 SD) and increased to 0.12 +/- 0.15 in urine samples collected for four hours after the calcium load. A direct relationship between UCa/UCr ratio and urinary sodium (UNa)/UCr ratio was observed (r = .57, P less than .01). In six children, calcium loading studies were repeated without prior restriction of dietary calcium. Dietary calcium intake before the calcium loading had little effect upon UCa/UCr ratio before the calcium in these six children (0.068 vs 0.08); however, UCa/UCr values after the calcium load were significantly lower (0.08 vs 0.15) when no dietary calcium restriction preceded the calcium-loading study. These data may allow characterization of renal hypercalciuria and gastrointestinal hyperabsorption of calcium in children with urolithiasis.

Intravenous desmopressin acetate in children with sickle trait and persistent macroscopic hematuria.

Persistent gross hematuria associated with sickle hemoglobinopathy that fails to respond to conventional supportive therapy represents a difficult management dilemma. Two such patients with protracted, often painful, sickle trait macrohematuria are described. Both patients had normal renal anatomy and vasculature and had failed to respond to bed rest, intravenous hydration, and a trial of oral epsilon-aminocaproic acid. Patient 1 had normal coagulation function. Patient 2 had von Willebrand disease (decreased factor VIII antigen and quantitative ristocetin cofactor activity). Patient 1 responded to intravenous desmopressin acetate at a dose of 0.3 microgram/kg with a 155% increase in factor VIII clotting activity and a 135% increase in ristocetin cofactor and cessation of her macrohematuria within 18 hours after completion of the desmopressin infusion. She remained free of gross hematuria for 5 months with the exception of short-lived trauma-induced hematuria (in three voids) 6 weeks after desmopressin therapy. Patient 2 did not respond to intravenous desmopressin infusion despite a 234% and a 360% increase in factor VIII clotting activity and ristocetin cofactor, respectively. Intravenous desmopressin acetate may be helpful in halting protracted significant macrohematuria associated with sickle trait hemoglobinopathy in some patients when conventional management fails.

Varied types of urinary calculi in a patient with cystinosis without renal tubular acidosis.

Renal calculi have rarely been cited as a major manifestation of cystinosis. We report a case history of a child with multiple urate calculi and a calcium oxalate stone resulting from proximal tubular dysfunction that was not associated with bicarbonate wastage.

Ambulatory blood pressure patterns in children and adolescents: influence of renin-sodium profiles.

A renin-sodium nomogram for normotensive children and adolescents was developed at our institution. The ambulatory blood pressure patterns of subjects classified by the nomogram were then compared. A biracial sample of 159 children and adolescents were classified as having a low, intermediate, or high renin-sodium profile based on the relationship between their plasma renin activity and 24-hour urinary sodium excretion. Casual (106/58 vs 107/61 vs 106/62 mm Hg) and awake (116/69 vs 117/69 vs 116/70 mm Hg) blood pressure values were comparable among subjects with low, intermediate, and high renin-sodium profiles. Subjects with high renin-sodium profiles, however, had a smaller decline in systolic blood pressure with sleep than did subjects with low renin-sodium profiles (7 vs 11 mm Hg; P less than .04), and higher diastolic blood pressure readings during sleep than subjects with intermediate renin-sodium profiles (65 vs 62 mm Hg; P less than .05). Subjects with high renin-sodium profiles also had greater variance of diastolic blood pressure readings during sleep than either subjects with low renin-sodium profiles (P less than .01) or those with intermediate renin-sodium profiles (P less than .02). The blunted nocturnal decline and increased nocturnal variance of blood pressure among subjects with high renin-sodium profiles may be a marker or mechanism for the future development of essential hypertension.

Acute renal failure at onset of therapy for advanced stage Burkitt lymphoma and B cell acute lymphoblastic lymphoma.

Aggressive therapeutic maneuvers to reduce the risk for acute renal failure are routine in the management of children receiving therapy for advanced stage Burkitt lymphoma and B cell acute lymphoblastic leukemia. The case histories of 40 children entered into a prospective treatment protocol for high-risk disease revealed that ten of 40 patients (25%) had acute renal failure, two at the time of hospital admission and eight in whom renal insufficiency developed 12 to 132 hours following initiation of cytotoxic chemotherapy. Admission values for serum lactic dehydrogenase and serum uric acid were not statistically different between patients with and without subsequent renal failure. Urine output in the 12 hours prior to antineoplastic therapy was 2.9 +/- 0.8 mL/kg/h in the eight children in whom renal failure developed and 5.3 +/- 0.4 mL/kg/h in the patients who did not (P less than .01). The urinary flow rate in the 24 hours following initiation of chemotherapy was significantly lower in children in whom renal impairment developed (1.0 +/- 0.2 mL/kg/h, mean +/- SE) compared with those who did not (3.7 +/- 0.3 mL/kg/h, P less than .001). Renal failure could not be attributed to hyperuricemia or hyperphosphatemia in the majority of patients with renal failure. One to four hemodialysis treatments (2.5 +/- 0.3) were required for the ten patients. Serum creatinine concentrations returned to normal in the nine survivors. Response to initial antineoplastic therapy was not affected by the presence of renal failure. Renal failure continues to be a major clinical problem in children with Burkitt lymphoma and B cell lymphoblastic leukemia.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical approach to children with urolithiasis.

Urinary stones are being recognized more frequently in children. As a result of major advancements in the urological therapies available to children with obstructed uropathy, infection-related stones no longer dominate the clinical manifestations of pediatric urolithiasis. Clinical manifestations of urolithiasis in children differ somewhat from adults and change during childhood. Causes of urolithiasis in children are remarkably similar to those of adults, although diagnostic criteria frequently vary throughout childhood. Hypercalciuria is the most common metabolic cause of pediatric urolithiasis. This article presents a general overview of urolithiasis in children and a practical approach to the medical evaluation of such children.

Content analysis of prime-time television medical news. A pediatric perspective.

OBJECTIVES: To assess child health news broadcasts by a major regional television station and to evaluate the attitudes of parents and pediatricians about the context and value of television news reports. DESIGN: Videotaping 6 months of consecutive evening news telecasts (Monday and Friday). Self-administered surveys given to a convenience sample of parents and mailed to community pediatricians. SETTING: Local and national newscasts of prime-time coverage by a major metropolitan television station. PARTICIPANTS: One hundred forty-four members of the Buffalo (NY) Pediatric Society and 87 parents of children in the outpatient or inpatient departments of The Children's Hospital, Buffalo. RESULTS: Pediatric issues were presented in 15% of local and 21% of national medical news stories. Adult-specific issues were addressed in 48% of local and 33% of national medical news reports. Local pediatric news reports focused on behavior (22%) and major illnesses (22%); national pediatric news concentrated on nutrition (30%), allergy (21%), and major illnesses (21%). Seventy percent of local and 85% of national pediatric news reports referenced an informative source. Fifty-one (59%) of the 87 parents and 69 (48%) of the 144 pediatricians consider television news to be an effective means of increasing awareness of child health issues. Parents and physicians recommended pediatric emergencies, safety, disease prevention, and adolescent issues as important areas of emphasis for television news. Fifty-one percent of the parents (44) and 48% of the pediatricians (69) believed that television reports increase knowledge of how to access local health resources. CONCLUSIONS: Television news reports are important sources of child health information. Pediatric topics on local and national news programs often do not focus on topics considered of highest priority by parents and pediatricians. Greater awareness by pediatricians of the potential value of television news as a tool for public health education is warranted.

Self-reports of salt intake by 10- to 18-year-olds: relationship to urinary sodium excretion.

Our data indicated that self-reports of consumption of salty foods by children and adolescents were associated with 24-hour urinary sodium excretion. Specifically, youths 10 to 18 years of age who selected a poster depicting high-sodium foods excreted significantly more sodium than youths who selected a poster depicting low-sodium foods. Future research is needed to refine simplified self-report measures, to corroborate the validity of the measures, and to extend the studies to other samples, e.g., younger children.

Prolonged hypocomplementemia in poststreptococcal acute glomerulonephritis.

Complement levels conventionally return to normal in eight weeks in patients with poststreptococcal acute glomerulonephritis (PSAGN). The objective of this study was to determine the significance of prolonged hypocomplementemia (> 8 weeks) in this group of patients. Between April 1993 and January 1995, 20 patients were followed prospectively for a mean of 6 months (range 3-20 months after the episode of PSAGN. Serum C3 concentrations were measured at diagnosis and at regular intervals. Five patients (26%) had prolonged hypocomplementemia. Percutaneous renal biopsies were performed in three patients which revealed findings consistent with the clinical diagnosis of PSAGN. All of these patients showed gradual improvement of their symptoms; some have persistent microscopic hematuria without proteinuria. Kidney function is normal in all despite hypocomplementemia. We conclude that hypocomplementemia (> 8 weeks) with resolving features of acute glomerulonephritis does not exclude the diagnosis of PSAGN, and a renal biopsy may be deferred if there is clinical improvement.

Cerebrovascular complications in children with nephrotic syndrome.

Although the nephrotic syndrome is known to be a hypercoagulable state, cerebral arterial thrombosis associated with the nephrotic syndrome is an uncommon yet treatable cause of stroke syndrome in children. We report 2 children, 1 with congenital nephrotic syndrome and the other with minimal change nephrotic syndrome, who developed cerebral arterial thrombosis. The complication was fatal in 1 patient.

Morphology of urinary red blood cells: a simple guide in localizing the site of hematuria.

The determination of whether urinary red blood cells originate from the kidneys or bladder allows the practitioner to evaluate children with hematuria more efficiently and economically. Recently, examination of the morphology of urinary red blood cells has proven to be a promising adjunct in the evaluation of hematuria. The application of this new office procedure is discussed.

Uric acid metabolism in children.

The renal excretion of uric acid in children differs quantitatively, and perhaps qualitatively, from that in adult humans. The younger the child, the greater the renal clearance of uric acid and the greater the excretion of uric acid expressed as mg per kg body weight. During infancy, the reduced ability to maximally concentrate the urine may protect against precipitation of uric acid crystals within the kidney. Conversely, the extremely high urinary uric concentrations places the very small infant at jeopardy during sudden increases in the filtered load of uric acid. Understanding the pharmacologic and physiologic modulators of renal uric acid clearance will allow the pediatrician to minimize the risk of uric acid nephropathy, and to understand the implications of uric acid in the serum or urine in children with fluid and electrolyte disorders. Certainly evaluation of serum and urinary uric acid concentrations is essential in any child with acute renal failure.

The alternate complement pathway. A possible role in a patient with focal glomerular sclerosis.

A boy had focal segmental glomerular sclerosis after the resolution of an unusual transient functional defect in activation of the alternate complement pathway. Prior to 1 year of age, the patient suffered repeated serious bacterial infections that were associated with an inability to opsonize Escherichia coli ON 2 in vitro. Serum levels of complement components were normal. Shortly after resolution of the complement defect, nephrotic syndrome developed. Properdin and C3 were identified in sclerotic glomeruli, which suggests that the ability to activate the alternate complement pathway played a role in the pathogenesis of glomerular sclerosis.

Renal tubular disorders in the neonate.

Renal tubular disorders are uncommon in the newborn period, but, when present, they may produce complex life-threatening alterations in the composition of the intracellular and extracellular fluid compartments. Because of the infrequency with which these disorders are encountered; clinicians are often uncertain of the appropriate diagnostic evaluation. The authors believe that localizing major neonatal renal tubular disorders to the proximal and distal nephron will assist physicians in developing a pathophysiologic understanding of these conditions.

Urolithiasis and enteric hyperoxaluria in a child with steatorrhea.

Malabsorptive states are frequently associated with increased urinary oxalate excretion. The authors describe a 10-year-old girl with steatorrhea, hyperoxaluria, and a renal calculus in a single functioning kidney. Successful management of steatorrhea corrected both the chronic diarrhea and hyperoxaluria. Enteric hyperoxaluria is a well-known etiology of calcium oxalate urolithiasis in adults. Pediatricians caring for children with malabsorptive conditions should be aware of the risk of urinary calculus formation as a result of increased dietary oxalate absorption.

Changing pattern of glomerular disease at Beijing Children's Hospital.

Current clinical experience with glomerular disease at a pediatric referral center in Beijing, China, was reviewed. In 1992, renal disorders accounted for 505 of a total 6,885 (7.3%) pediatric medical discharges. Acute glomerulonephritis accounted for 30% of renal diagnoses, while nephrotic syndrome accounted for 28% and Henoch-Schönlein purpura nephritis accounted for 16% of renal disease. Mortality in children with renal disease was 0.4% (two of 505). All children with acute glomerulonephritis recovered or improved at last follow-up, regardless of the relationship to a streptococcal infection. In children with uncomplicated nephrotic syndrome, 91% had a complete or partial response to corticosteroids. Nephritis developed in 81 of 278 patients with Henoch-Schönlein purpura (29%). Since 1956, a dramatic decrease in the diagnosis of acute glomerulonephritis has occurred at this pediatric hospital. Nephrotic syndrome, in contrast, has increased from 45.3 cases per year in the 1956-to-1965 decade to 146 cases annually in the period from 1986 to 1992. Similarly, Henoch-Schönlein purpura has increased from 45.3 cases annually in the 1956-to-1965 period to 238 cases per year in the past 6 years. The incidence of nephritis in patients with Henoch-Schönlein purpura has remained constant at 29% in the past 36 years. These data should be helpful for individuals and institutions who are planning educational or clinical collaborations with pediatric nephrologists in China.