Prevalence of lower urinary tract symptoms in school-age children.

Epidemiological studies have demonstrated rates of incontinence and enuresis as high as 20% in school-age children. This cross-sectional study aimed to investigate the prevalence of lower urinary tract (LUT) symptoms in 739 children aged 6-12 years enrolled in three government schools with different socioeconomic levels in Minas Gerais, Brazil. Symptoms of LUT were evaluated using a modified version of the Dysfunction Voiding Scoring System in which the cutoff point considered as an indicator of LUT dysfunction is >6 for girls and >9 for boys. Children with a score indicative of symptoms received an educational booklet on the functioning of the LUT and were sent for clinical evaluation. LUT dysfunction symptoms were detected in 161 (21.8%) children. Symptoms were most frequent in girls (p < 0.001), children aged 6-8 (p < 0.028), and attended the school with the lowest social level (p < 0.001). Intestinal constipation was the most prevalent finding (30.7%), independent of LUT score. The most common urinary symptoms in children with an elevated score were diurnal urinary incontinence (30.7%), holding maneuvers (19.1%), and urinary urgency (13.7%). Stress factors were associated in 28.4% of children. Our findings suggest that LUT symptoms must be investigated carefully at routine pediatric visits.

Plasma and urinary levels of cytokines in patients with idiopathic hypercalciuria.

BACKGROUND: Recent studies suggest that cytokines modulate bone turnover. Idiopathic hypercalciuria (IH) seems to be associated with bone mineral loss. Therefore, the aim of this study was to assess cytokines involved in bone turnover in patients with IH. METHODS: Plasma and spot-urine levels of interleukin (IL)-1ß, IL-6, IL-8, tumor necrosis factor alpha (TNF-α), transforming growth factor ß1 (TGF-ß1), and monocyte chemoattractant protein (MCP-1) were measured in 70 children and adolescents with IH and in 37 healthy controls. Patients with IH were subdivided according to their calciuria at the time of sample collection: ≥4 mg/kg/day (persistent IH, n=27) and below 4 mg/kg/day (controlled IH, n=43). Cytokines were determined by enzyme-linked immunoassay. RESULTS: Plasma and urinary concentrations of IL-1ß, IL-6, IL-8, and TNF-α were undetectable in all groups. No differences were found between controlled and persistent hypercalciuria for plasma and urinary levels of MCP-1 and TGF-ß1. On the other hand, MCP-1 levels were significantly higher in both subgroups of IH in comparison to healthy controls. Furthermore, urinary MCP-1 levels of IH patients correlated positively with bone mineral content (p=0.013). CONCLUSION: Although cytokine measurements did not allow the differentiation between persistent and controlled IH, our findings suggest that MCP-1 might play a role in patients with IH.

Combined use of late phase dimercapto-succinic acid renal scintigraphy and ultrasound as first line screening after urinary tract infection in children.

PURPOSE: The aim of this study was to evaluate the diagnostic accuracy of dimercapto-succinic acid renal scintigraphy and renal ultrasound in identifying high grade vesicoureteral reflux in children after a first episode of urinary tract infection. MATERIALS AND METHODS: A total of 533 children following a first urinary tract infection were included in the analysis. Patients were assessed by 3 diagnostic imaging studies, renal ultrasound, dimercapto-succinic acid scan and voiding cystourethrography. The main event of interest was the presence of high grade (III to V) vesicoureteral reflux. The combined and separate diagnostic accuracy of screening methods was assessed by calculation of diagnostic OR, sensitivity, specificity, positive predictive value, negative predictive value and likelihood ratio. RESULTS: A total of 246 patients had reflux, of whom 144 (27%) had high grade (III to V) disease. Sensitivity, negative predictive value and diagnostic OR of ultrasound for high grade reflux were 83.3%, 90.8% and 7.9, respectively. Dimercapto-succinic acid scan had the same sensitivity as ultrasound but a higher negative predictive value (91.7%) and diagnostic OR (10.9). If both tests were analyzed in parallel by using the OR rule, ie a negative diagnosis was established only when both test results were normal, sensitivity increased to 97%, negative predictive value to 97% and diagnostic OR to 25.3. Only 9 children (6.3%) with dilating reflux had an absence of alterations in both tests. CONCLUSIONS: Our findings support the idea that ultrasound and dimercapto-succinic acid scan used in combination are reliable predictors of dilating vesicoureteral reflux.

Behavioral disorders and low quality of life in children and adolescents with chronic kidney disease.

Recent years has seen an increasing interest in the quality of life (QOL) of children with chronic kidney disease (CKD). The objective of this cross-sectional study was to investigate the prevalence of behavioral disorders and to assess the health-related QOL (HRQOL) in 136 patients with CKD. To estimate the prevalence of behavior disorders and analyze HRQOL, we used the Strengths and Difficulties Questionnaire (SDQ) and Pediatric Inventory of Quality of Life (PedsQL) Core Scales as assessment tools for both the patients and caregivers. When compared to healthy controls, the CKD group had significantly lower scores in almost all PedsQL domains. After adjustment, only absence of religion/other religions remained significantly associated with a lower global HRQOL score [odds ratio (OR) 6.2, P=0.009]. Among the parents, two factors remained significantly associated with a lower global HRQOL score: patients' age >10 years (OR 5.4, P=0.033) and absence of religion/other religions (OR 3.2, P=0.038). The CKD group demonstrated a higher proportion of behavioral and emotional disorders in all SDQ domains. There was a negative correlation between the presence of behavior and emotional disorders and HRQOL score (r= -0.552, P<0.001). Our findings suggest the importance of evaluating behavioral and social repercussions of CKD in order to improve the life quality of this pediatric population.

Duration of temporary catheter use for hemodialysis: an observational, prospective evaluation of renal units in Brazil.

BACKGROUND: For chronic hemodialysis, the ideal permanent vascular access is the arteriovenous fistula (AVF). Temporary catheters should be reserved for acute dialysis needs. The AVF is associated with lower infection rates, better clinical results, and a higher quality of life and survival when compared to temporary catheters. In Brazil, the proportion of patients with temporary catheters for more than 3 months from the beginning of therapy is used as an evaluation of the quality of renal units. The aim of this study is to evaluate factors associated with the time between the beginning of hemodialysis with temporary catheters and the placement of the first arteriovenous fistula in Brazil. METHODS: This is an observational, prospective non-concurrent study using national administrative registries of all patients financed by the public health system who began renal replacement therapy (RRT) between 2000 and 2004 in Brazil. Incident patients were eligible who had hemodialysis for the first time. Patients were excluded who: had hemodialysis reportedly started after the date of death (inconsistent database); were younger than 18 years old; had HIV; had no record of the first dialysis unit; and were dialyzed in units with less than twenty patients. To evaluate individual and renal unit factors associated with the event of interest, the frailty model was used (N = 55,589). RESULTS: Among the 23,824 patients (42.9%) who underwent fistula placement in the period of the study, 18.2% maintained the temporary catheter for more than three months until the fistula creation. The analysis identified five statistically significant factors associated with longer time until first fistula: higher age (Hazard-risk - HR 0.99, 95% CI 0.99-1.00); having hypertension and cardiovascular diseases (HR 0.94, 95% CI 0.9-0.98) as the cause of chronic renal disease; residing in capitals cities (HR 0.92, 95% CI 0.9-0.95) and certain regions in Brazil - South (HR 0.83, 95% CI 0.8-0.87), Midwest (HR 0.88, 95% CI 0.83-0.94), Northeast (HR 0.91, 95% CI 0.88-0.94), or North (HR 0.88, 95% CI 0.83-0.94) and the type of renal unit (public or private). CONCLUSION: Monitoring the provision of arteriovenous fistulas in renal units could improve the care given to patients with end stage renal disease.

Bone disease and cytokines in idiopathic hypercalciuria: a review.

Bone remodeling is a continuous and dynamic process of skeletal destruction and renewal. A complex regulatory mechanism with the participation of several cytokines precisely defines the role of osteoclasts in the chain of events leading to bone resorption. There are multiple mechanisms underlying the regulation of bone resorption, which can involve increased calcium excretion and decreased bone density in patients with idiopathic hypercalciuria (IH). However, the pathogenesis of bone mass reduction in IH remains uncertain. The purpose of this review is to summarize the recent published evidence on the possible mechanisms by which cytokines could be associated with the pathogenesis of IH.

Depression, anxiety and quality of life impairment in parents of children with functional lower urinary tract dysfunction.

BACKGROUND: Lower urinary tract dysfunction (LUTD) is a common clinical condition in children, frequently associated with emotional issues both among the patients and their families. The objective of the present study was to measure depressive and anxious symptoms and quality of life (QoL) in parents of LUTD patients. METHODS: This cross-sectional study applied Beck Depression and Anxiety Inventories and WHOQOL-Bref to 88 caregivers of children with LUTD followed at a tertiary care center. The prevalence of mental disorders in children and adolescents was assessed using the Child Behavior Check List (CBCL 6-18) answered by their caregivers. The association of clinical features and emotional aspects related to the caregivers' quality of life was evaluated through non-parametric correlation (Spearman) and multiple linear regression analysis. RESULTS: Most of the caregivers were mothers (88%), with a mean age of 41.5 (SD 8.7 years), 67% of them married or in a stable union, and 38% had not completed elementary school. Considering 19 as the cutoff point for the Beck scale, 44% of the sample had a clinical score for depressive symptoms and 43% for anxious symptoms. According to the parents' report, 56% of children with LUTD had a clinical score for behavioral problems in CBCL. Parents' QoL was impaired, and the predictors of poor QoL were the age of the patients and presence of depressive/anxious symptoms in caregivers. Parents' depression/anxiety symptoms and poor QoL significantly correlated with behavioral problems in their children. The CBCL total problems score correlated both to depression (r = 0.38, p < 0.01) and to anxiety in parents (r = 0.49, p < 0.01) (Figure). CONCLUSIONS: These findings indicate a possible emotional impact of LUTD in patients' caregivers. Our study suggests that an approach to the family of LUTD patients' may be an important therapeutic resource for an effective clinical control of this condition.

Predictive factors of progression to chronic kidney disease stage 5 in a predialysis interdisciplinary programme.

BACKGROUND: The clinical course of chronic kidney disease (CKD) in children is heterogeneous and has not been fully established. The aim of this retrospective cohort study was to identify predictive factors associated with the progression of CKD among the children and adolescents admitted to a Predialysis Interdisciplinary Management Programme (PDIMP). METHODS: We analysed the following variables at admission: age, gender, race, blood pressure, primary renal disease, Z-scores for weight and height, CKD stage and degree of proteinuria. Two time-dependent covariates were considered: hypertension and proteinuria. CKD stage 5 was assigned as a dependent variable. Time-fixed and time-dependent Cox regression analyses were applied to evaluate renal survival. RESULTS: One hundred and seven patients with CKD stage 2-4 were followed up for a median time of 94 months. Fifty-seven patients (53.3%) progressed to CKD stage 5. After adjustment for time-fixed model, three baseline variables were found to be independent predictors of CKD stage 5: glomerular disease (hazard ratio, HR = 3.0, P = 0.015), CKD stage 4 (HR = 2.6, P = 0.001) and severe proteinuria (HR = 4.1, P = 0.006). After adjustment for the time-dependent model, three variables were found to be independent predictors of CKD stage 5: proteinuria as time-dependent covariate (HR = 1.9, P = 0.041), CKD stage 4 (HR = 2, P = 0.0086) and baseline serum albumin <3.5 g/dl (HR = 2.6, P = 0.0015). CONCLUSIONS: Taking into account manageable factors, further prospective controlled studies are necessary to assess intervention measures in order to possibly modify the clinical course of CKD in children.

Independent risk factors for renal damage in a series of primary vesicoureteral reflux: a multivariate analysis.

AIM: The aim of this study was to investigate risk factors associated with different extents of renal parenchyma involvement in a paediatric series of primary vesicoureteral reflux (VUR). METHODS: A total of 549 patients with VUR were analyzed. The variable of interest was renal scar, assessed by technetium-99m dimercaptosuccinic acid scan, and classified into three subtypes: focal scar, multiple cortical scarring and diffuse scars with a contracted renal unit. The multinomial regression model was applied to identify independent variables associated with each subtype of renal damage. RESULTS: After adjustment, four variables remained independently associated with a contracted renal unit: reflux grades III-V (odds ratio (OR)=9.7; 95% confidence interval (CI) = 4.1-21.0), age at diagnosis (OR=3; 95% CI=1.6-5.1), unilateral reflux (OR=2.1; 95% CI=1.2-3.8), and male sex (OR=2; 95% CI=1.1-3.8). Two variables were associated with multiple scars: reflux grades III-V (OR=13.8; 95% CI=7.4-26.0) and age at diagnosis (OR=1.9; 95% CI=1.2-3.0). Two variables were associated with a focal scar: reflux grades III-V (OR=7.9, 95% CI CI=3.8-16.4) and male sex as a protective factor (OR=0.5; 95% CI=0.25-1.0). CONCLUSION: Our findings suggest that the development of a contracted renal unit is probably due to congenital malformation, more commonly observed in male infants with high-grade reflux.

Risk factors for recurrent urinary tract infections in a cohort of patients with primary vesicoureteral reflux.

BACKGROUND: Knowledge of risk of urinary tract infection (UTI) recurrence in vesicoureteral reflux (VUR) can help clinicians make therapeutic decisions. The aim of this retrospective cohort study was to identify risk factors associated with recurrent urinary tract infection in children with VUR. In addition, a risk score that might predict the chance of UTI recurrence was also proposed. METHODS: Between 1970 and 2007, 740 patients were diagnosed with VUR and were systematically followed up at a single tertiary Renal Unit. Recurrent UTI was defined as more than 1 episode during follow-up. A binary logistic regression model was applied to identify variables independently associated with recurrent UTIs. RESULTS: During follow-up, information was obtained on 58,856 person-months. Recurrent UTIs occurred in 120 (16.2%) patients. The overall incidence rate of UTI was 8.4 episodes per 1000 person-months (95% CI, 7.7, 9.2). After adjustment by multivariable analysis, 5 variables were independent predictors of recurrent UTI: UTI as clinical presentation, age < 6 months, female gender, dysfunctional elimination syndrome, and severe grade of reflux. The risk for recurrent UTI was classified as low in 24% of children, medium in 42%, and high in 34%. UTI incidence rates per 1000 person-months were 4.3 (95% CI, 3.2, 5.6), 7.9 (95% CI, 6.7, 9.1), and 11.3 (95% CI, 9.9, 12.8) for low-, medium-, and high-risk groups, respectively. CONCLUSION: The prediction model of recurrent UTI allows an early recognition of patients at risk for long-term morbidity and might contribute to the formulation of therapeutic strategies.

Clinical outcome of children with chronic kidney disease in a pre-dialysis interdisciplinary program.

The purpose of this retrospective cohort study was to describe the outcome of 107 patients with chronic kidney disease (CKD) admitted to a pre-dialysis interdisciplinary management program from 1990 to 2006. The events of interest were progression to CKD stage 5 (renal survival), patient survival, hypertension, and somatic growth. Survival was studied by the Kaplan-Meier method. Patients were classified into four groups according to their primary renal disease: congenital nephro-uropathies; glomerular diseases; cystic disease, and miscellaneous. Median follow-up time was 94 months [Interquartile (IQ) range 38-145]. The probability of reaching CKD stage 5 was estimated to be 36% by 5 years after admission. As a whole, the mean estimated glomerular filtration rate (GFR) decrease per year was 5.8 ml/min per 1.73 m(2) body surface area [standard deviation (SD) 12.4]. The glomerular diseases group showed a median rate of GFR deterioration of 10 ml/min per 1.73 m(2) per year (IQ range -24 to -5.7), whereas the median rate of GFR deterioration for the groups with cystic diseases, congenital nephro-uropathies, and miscellanea were 2.5 ml/min (IQ range -10 to +0.34), 2.2 ml/min (IQ range -5.0 to -0.52), and 0.36 ml/min (IQ range -2.5 to +2.6), respectively (P < 0.001). The results of this study support the view that children and adolescents with glomerular diseases present a faster deterioration of renal function. Therefore, patients with glomerular diseases need to be referred early to a pediatric nephrology center so that suboptimal pre-dialysis care might possibly be avoided.

Risk factors for renal scarring in children and adolescents with lower urinary tract dysfunction.

Risk factors for renal scarring in children with lower urinary tract dysfunction (LUTD) were evaluated. The medical records of 120 patients were assessed concerning gender, presence of vesicoureteric reflux (VUR), bladder capacity, detrusor overactivity, residual urine, febrile urinary tract infection (UTI), bacteriuria, constipation, detrusor sphincter incoordination (DSI), high detrusor pressure at maximal cystometric capacity (PMCC), low compliance, and thickness and trabeculation of the bladder wall. Renal scarring was diagnosed by (99m)technetium-dimercaptosuccinic acid renal scan (DMSA). Renal scarring was detected in 38 patients (31%). VUR, UTI, decreased bladder capacity, urinary residue, and trabeculated and thick bladder wall were associated with scarring at univariate analysis. Multivariate analysis showed VUR (P < 0.0001) as the independent risk factor for renal scarring. Thickness of the bladder wall was a marginal risk factor (P = 0.07). Although UTI was not a risk factor, it was associated with VUR (P = 0.03). In our analysis, VUR was the main risk factor; however, renal scarring was probably due to multifactorial causes, as VUR was associated with UTI.

Risk of hypertension in primary vesicoureteral reflux.

The aim of this report was to estimate the risk of hypertension in children with primary vesicoureteral reflux (VUR). Between 1970 and 2004, 735 patients were diagnosed with VUR at a single tertiary renal unit. Of 735 patients, 664 (90%) were systematically followed and had multiple measurements of blood pressure. Hypertension was defined as values persistently above 95th for age, sex, and height in three consecutive visits. Risk of hypertension was analyzed by the Kaplan-Meier method. Of 664 patients followed, 20 (3%) developed hypertension. The estimated probability of hypertension was 2% (95%CI, 0.5%-3%), 6% (95%CI, 2%-10%), 15% (95%CI, 11%-20%) at 10, 15, and 21 years of age, respectively. The prevalence of hypertension has increased with age: it was 1.7% for patients with 1 yr-9.9 yr, 1.8% for adolescents with 10 yr-14.9 yr, 4.7% for patients with 15-19.9 yr, and 35% for patients>20 years at the end of the follow-up (P<0.001). It was estimated by survival analysis that 50% of patients with unilateral and bilateral renal damage would have sustained hypertension at about 30 and 22 years of age, respectively. Hypertension increased with age and was strongly associated with renal damage at entry in an unselected population of primary VUR.

Predictive factors of resolution of primary vesico-ureteric reflux: a multivariate analysis.

OBJECTIVE: To identify independent factors predicting the resolution of primary vesico-ureteric reflux (VUR) in a cohort of medically managed children. PATIENTS AND METHODS: Between 1977 and 2003, 506 children were diagnosed with VUR and were conservatively managed and prospectively followed. All of the children were maintained on antibiotic prophylaxis. Follow-up imaging consisted of voiding cysto-urethrography (VCUG) or a direct isotope cystogram at intervals of 2-3 years. The predictive factors used are based on the patient data at the time of entry in the protocol. The dependent variable was VUR resolution. The criterion for resolution was based on a single negative VCUG or direct isotope cystogram. A survival analysis identified variables significantly associated with VUR resolution. Cox's regression model was applied to identify variables independently associated with the dependent variable. RESULTS: After adjustment, four variables remained as independent predictors of VUR resolution: nonwhite race, relative risk (95% confidence interval) of 1.5 (1.1-1.9; P = 0.009); mild grade of VUR, 3.3 (2.1-5.3; P < 0.001); absence of renal damage, 3.3 (2.4-4.5; P < 0.001); and absence of dysfunctional voiding, 2.0 (1.4-3.1; P < 0.001). For mild VUR, three variables were significantly associated: male gender, 1.7 (1.1-2.6; P = 0.012); absence of renal damage, 3.4 (1.8-6.4; P < 0.001); and unilateral VUR, 1.6 (1.1-2.3; P = 0.004). For moderate/severe VUR, three variables were significantly associated: nonwhite race, 1.7 (1.1-2.6; P = 0.01); absence of renal damage, 3.0 (2.0-4.4; P < 0.001); and absence of dysfunctional voiding, 2.8 (1.4-5.5; P = 0.004). CONCLUSION: Few factors are amenable to intervention to modify the natural history of VUR. According to our findings, there are only two possible interventions: avoiding renal scars and managing voiding dysfunction.

Clinical course of 110 children and adolescents with primary focal segmental glomerulosclerosis.

The purpose of this retrospective cohort study was to report the clinical course of children and adolescents with primary focal segmental glomerulosclerosis (FSGS). The records of 110 patients with biopsy-proven FSGS admitted between 1972 and 2004 were retrospectively reviewed. Demographic, clinical and laboratory data were recorded and histopathological data were reanalyzed by one pathologist who had no information about the outcome of the patients. Renal survival analysis was performed using the Kaplan-Meier method. Differences between subgroups (response to corticosteroids) were assessed by the two-sided log rank test. The median age at admission was 5 years (range: 1-15 years). Forty-two patients (38.2%) presented with hematuria at admission, and 55 (50%) presented blood pressure levels above the 95th percentile. Mean follow-up time was 10 years (SD 5.5). Twenty-four patients (21.8%) presented chronic kidney disease (CKD). It was estimated that the probability of CKD was 8% at 5 years, 17% at 10 years, and 32% at 15 years after diagnosis of nephrotic syndrome. In conclusion, on the basis of the clinical and histological characteristics observed, apparently our cohort of idiopathic FSGS is comparable with other published series. However, the long-term overall renal survival seems to be better in our cohort.

Predictive factors of chronic kidney disease in primary focal segmental glomerulosclerosis.

Renal histological features of focal segmental glomerulosclerosis (FSGS) are found in 75% of pediatric patients with steroid-resistant nephrotic syndrome. In order to evaluate the predictive factors of chronic kidney disease (CKD), we retrospectively reviewed the records of 110 children with biopsy-proven FSGS admitted between 1972 and 2004. Renal survival was analyzed by the Kaplan-Meier method and Cox's regression model. Two multivariate models were developed: (1) from the onset of symptoms to the occurrence of CKD and (2) from the time of renal biopsy to CKD. Mean follow-up time was 10 years [standard deviation ((SD) 5.5], and 24 patients (21.8%) progressed to CKD. At baseline, after adjustment three variables remained as independent predictors of CKD: age >6.5 years (RR=3.3, 95% CI=1.3-7.8), creatinine >1 mg/dl (RR=2.5, 95% CI=0.97-6.5), and non-response to steroids (RR=7.3, 95% CI=2.7-19.7). In a model with continuous variables only age and non-response to steroids were associated with CKD. At the time of renal biopsy, after adjustment two variables remained as independent predictors of CKD: hematuria (RR=3.0, 95% CI=1.2-7.3) and creatinine >0.8 mg/dl (RR=4.3, 95% CI=1.7-10.6). In a model with continuous variables four factors predicted CKD: age, creatinine, hematuria, and percentage of global sclerosis.

Bone density measurements in pediatric patients with renal osteodystrophy.

Peripheral quantitative computed tomography (pQCT) can selectively measure the densities of cortical and trabecular bone, but there is limited information about its use in patients with renal osteodystrophy. Thus pQCT (Norland XCT-2000, Stratec, Pforzheim, Germany) was performed at the ultradistal radius in 21 patients aged 16+/-3.6 (SD) years on continuous cycling peritoneal dialysis. Trabecular bone density (TBD) was higher in patients, 206+/-16 mg/cm(3), than in controls, 182.7+/-24.8 mg/cm(3) ( P<0.0001), whereas cortical bone density (CBD) was lower in patients, 946.5+/-147.5 mg/cm(3), than in controls, 1,153+/-25.4 mg/cm(3) ( P<0.001). TBD was inversely correlated with age ( r=-0.59, P=0.05), height ( r=-0.59, P<0.01), and weight ( r=-0.51, P<0.05). In contrast, CBD was positively correlated with age ( r=0.53, P<0.05), height ( r=0.56, P<0.05), and weight ( r=0.53, P<0.05). CBD was inversely related to serum alkaline phosphatase ( r=-0.71, P<0.001) and parathyroid hormone levels ( r=-0.50, P<0.05). In patients with adynamic bone, TBD was less, 192+/-9 mg/cm(3), than in those with high-turnover lesions, 215+/-13 mg/cm(3), P<0.001. CBD, however, was lower in patients with high-turnover lesions, 900+/-151 mg/cm(3), than in those with low turnover, 1,022+/-111 mg/cm(3), P<0.05. Compared with controls, in patients with high-turnover lesions, CBD was lower ( P<0.0001) and TBD higher ( P<0.0001). These findings suggest that pQCT may be an additional tool in the assessment of renal osteodystrophy.

Bladder dysfunction: diagnosis with dynamic US.

PURPOSE: To evaluate the role of dynamic ultrasonography (US) in the diagnosis of bladder dysfunction and to compare dynamic US with urodynamic study, which is considered to be the standard in the diagnosis of bladder dysfunction. MATERIALS AND METHODS: Images from 71 pairs of examinations in 63 patients (median age, 7.9 years; range 1.0-17.4 years) were included in the study. After the child consumed adequate fluids in an appropriate environment, natural filling of the bladder occurred, and dynamic US was used to evaluate detrusor activity, determine capacity of the bladder, and estimate residual urine volume. A urodynamic study was performed in every patient within 6 months of dynamic US and under the same treatment conditions. The paired Student t test was used to compare the maximal cystometric capacity values obtained with the two examinations. Analysis of validity was performed with the calculation of sensitivity, specificity, positive and negative predictive values, and their respective 95% confidence limits. RESULTS: The bladder capacity was not significantly different between dynamic US and urodynamic study (P =.12). Analysis of validity for the determination of the presence of clinically substantial residual urine showed 97.7% sensitivity and 100% specificity for dynamic US. The sensitivity and specificity of dynamic US in the detection of involuntary detrusor contraction were 93.0% and 88.9%, respectively. In the analysis of involuntary detrusor contraction with urine leakage, dynamic US showed sensitivity of 100% and specificity of 97.8%. CONCLUSION: Dynamic US is a sensitive method for the diagnosis of bladder dysfunction.

Predictive factors of progression of chronic renal insufficiency: a multivariate analysis.

The purpose of this study was to identify clinical, nutritional, and laboratory factors associated with the rate of progression of chronic renal insufficiency among children and adolescents admitted to a pre-end-stage renal failure (ESRF) interdisciplinary program. Sixty-two children and adolescents aged 2 months to 19 years with chronic renal failure on conservative management were prospectively followed from 1990 to 1999. The following variables were analyzed: age at admission, sex, race, blood pressure, primary renal disease, Z scores for weight and height, glomerular filtration rate (GFR), urea, and presence and degree of proteinuria. Progression to ESRF was assigned as a dependent variable. The analysis was conducted in two steps. In a univariate analysis, variables associated with ESRF outcome were identified by the log-rank test. Then, the variables that were significantly associated with adverse outcome were included in a multivariate analysis. This analysis, using the Cox proportional hazards model, was performed to identify variables that were independently associated with a worse prognosis. Only variables that remained independently associated with adverse outcome were included in the final model. Twenty-one (34%) patients evolved to ESRF during a median follow-up of 43 months. Two variables were identified as independent predictors of progression to ESRF: GFR under 30 ml/min (RR=3, 95% CI=1.7-5.3, P=0.0001) and severe proteinuria (RR=3.1, 95% CI=1.2-7.6, P=0.01). The combination of two factors-GFR lower than 30 ml/min and presence of severe proteinuria on admission-was an independent indicator of adverse outcome in children and adolescents with chronic renal insufficiency who were conservatively managed.