PURPOSE:It is thought that the function of a damaged kidney will deteriorate further with time because of impaired maturation and compensatory hyperfiltration. The aim of this study was to determine changes in relative renal function (RRF) over time in children with vesicoureteric reflux (VUR) and/or urinary tract infection (UTI) where the unilaterally scarred kidney was found to contribute 30% or less to overall function. PATIENTS AND METHODS:Children who met the inclusion criteria and had multiple radionuclide studies during a 12-year period were identified, and RRF was compared. RESULTS:Twenty-seven boys and 3 girls with a median age of 0.8 years (0.08-13.05 years) were included. Eight patients had unilateral VUR, 21 patients had bilateral VUR, and 1 patient had UTIs without VUR. Twenty-one patients underwent reimplantation surgery, and 9 were managed conservatively.At a mean follow-up of 2.64 years (0.26-6.77 years), there was a nonsignificant mean decrease in RRF from 19% (11%-28%) to 18% (9%-29%). The mean change in renal function was not affected by the severity of the initial RRF. CONCLUSIONS:In the medium term, there is no deterioration of RRF of unilaterally severely damaged kidneys associated with either VUR or UTI managed either surgically or conservatively. Boys are at a much greater risk of severe reflux nephropathy.

Voiding cystourethrography (VCUG) is commonly performed to screen for vesicoureteric reflux or other urological anomalies but has a potential to provoke distress in infants and children. We performed a systematic review of randomized controlled trials of interventions to reduce distress, pain or anxiety during VCUG. Eight trials (591 participants) met the inclusion criteria.Conclusion: Conscious sedation with midazolam effectively alleviates the distress of VCUG in children older than 1 year of age. Psychological preparation and warmed contrast medium may also be effective. Nitrous oxide 50% may be an alternative to midazolam, but further evidence is needed.

Voiding cystourethrography (VCUG) is commonly performed to screen for vesicoureteric reflux or other urological anomalies but has a potential to provoke distress in infants and children. We performed a systematic review of randomized controlled trials of interventions to reduce distress, pain or anxiety during VCUG. Eight trials (591 participants) met the inclusion criteria. Conclusion: Conscious sedation with midazolam effectively alleviates the distress of VCUG in children older than 1 year of age. Psychological preparation and warmed contrast medium may also be effective. Nitrous oxide 50% may be an alternative to midazolam, but further evidence is needed.

Cardiovascular (CVS) death accounts for almost a quarter of paediatric and young adult end stage kidney disease deaths (1) and traditional CVS risk factors are often evident at an early age in children with chronic kidney disease (CKD). Endothelial dysfunction is a precursor of atherosclerosis (2) and it has been documented to be present by the first decade of life in children with CKD. (3). Given that endothelial dysfunction occurs very early in the timeline of atherosclerosis, it would seem to be an attractive target for therapeutic intervention (4). There is some evidence that statins may improve endothelial dysfunction in nephrotic syndrome (5), and in adults with raised (6,7) and borderline raised (8) lipid levels. We therefore designed an intervention trial in children with CKD to determine whether we could improve endothelial dysfunction by using an HMG CoA reductase inhibitor (statin). Patients were included if lipid levels were ‡50th percentile (rather than the more conventional 95th percentile) because the risk of hyperlipidaemia seems to be continuous, evidenced by an almost linear correlation between increasing lipid levels and decreasing arterial distensibility in normal children (9). The objective of this study was to assess the effect of statin-associated cholesterol lowering on endothelial function, lipoprotein levels, C reactive protein (CRP), blood pressure (BP) and renal function in mildly hyperlipidaemic children with CKD stages 3–4 [estimated glomerular filtration rate (GFR) (10) <60 mL ⁄ min ⁄ 1.73 m]. A prospective, randomized double-blinded placebo controlled, crossover trial of atorvastatin 10 mg daily for 8 weeks in children (5–17 years of age; n = 8) with serum lipoprotein levels >50th percentile was conducted (i.e. each patient was studied before and after 8 weeks of placebo and atorvastatin with a 4-week washout period between treatment arms). Seven of eight children were taking Angiotensin Converting Enzyme Inhibitors (ACE-inhibitors) for renoprotection (not hypertension). Endothelial function was measured non-invasively by studying brachial artery reactivity by vascular ultrasound (ATL HDI 5000 Phillips, Bothell, Washington, DC, USA) (11). Change in brachial artery endothelium-dependent flow-mediated dilatation (FMD) was the primary end-point. It was estimated that in a crossover design with scans before and after intervention, 10 patients would detect a significant change in FMD of 3.6% (11) to provide 80% power at the 5% significance level. Unfortunately, placebo expiry and recruitment difficulty led to only eight patients participating in a pilot study. Patients were recruited from the renal clinic of Sydney Children’s Hospital and South Eastern Area Health and Central Sydney Ethics Committees approved the study. Total cholesterol and LDL significantly decreased during treatment by a mean of 1.3 ± 0.3 mmol ⁄ L p < 0.0001 and 1.1 ± 0.3 mmol ⁄ L respectively p < 0.0001 (paired student t test) (Table 1). Baseline FMD was normal with a mean of 9.75 ± 0.39% (SEM) and did not significantly alter after 8 weeks of atorvastatin (8.04 ± 1.02% p = 0.18) (Table 2). No significant change was seen in creatinine, BP, CRP, liver function tests, or creatinine kinase levels with atorvastatin. There was no significant correlation (Pearson) between vascular reactivity studies and serum creatinine or estimated GFR. There was no correlation between lipid concentrations, BP, BMI and FMD or glyceryl trinitrate (GTN) studies. Atorvastatin therapy for 8 weeks did not alter endothelial function in children with CKD despite a dose which achieved a significant reduction in LDL cholesterol. We postulate this may be attributable to the FMD results that Acta Pædiatrica ISSN 0803–5253

Kennedy, S E.1; Mackie, F E.1,2; Kainer, G1; Craig, E1; Rosenberg, A R.1,2 Author Information

Journal of Paediatrics and Child HealthVolume 44, Issue 5 p. 305-307 Tubulointerstitial nephritis: Drugs are not always to blame Fiona E Mackie, Corresponding Author Fiona E Mackie Department of Nephrology, Sydney Children's Hospital and University of NSW, NSW, AustraliaDr. Fiona Mackie, Department of Nephrology, Sydney Children's Hospital, High St, Randwick 2031, NSW, Australia. Fax: +61293821580; email: f.mackie@unsw.edu.auSearch for more papers by this authorAndrew R Rosenberg, Andrew R Rosenberg Department of Nephrology, Sydney Children's Hospital and University of NSW, NSW, AustraliaSearch for more papers by this authorGad Kainer, Gad Kainer Department of Nephrology, Sydney Children's Hospital andSearch for more papers by this author Fiona E Mackie, Corresponding Author Fiona E Mackie Department of Nephrology, Sydney Children's Hospital and University of NSW, NSW, AustraliaDr. Fiona Mackie, Department of Nephrology, Sydney Children's Hospital, High St, Randwick 2031, NSW, Australia. Fax: +61293821580; email: f.mackie@unsw.edu.auSearch for more papers by this authorAndrew R Rosenberg, Andrew R Rosenberg Department of Nephrology, Sydney Children's Hospital and University of NSW, NSW, AustraliaSearch for more papers by this authorGad Kainer, Gad Kainer Department of Nephrology, Sydney Children's Hospital andSearch for more papers by this author First published: 15 April 2008 https://doi.org/10.1111/j.1440-1754.2008.01303.xCitations: 4Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Citing Literature Volume44, Issue5May 2008Pages 305-307 RelatedInformation

A renal length discrepancy (RLD) of more than 10 mm by ultrasound (US) is accepted as a potential indicator of an underlying renal pathology; however, there are few supporting data for this in children. Our objective was to determine a cutoff at which RLD on US is a reliable predictor of dimercaptosuccinate acid (DMSA) scan abnormality. We present data from 90 patients who had both renal US and a DMSA scan, as well as DMSA scan results compared with bipolar RLD by US. Positive (PPV) and negative (NPV) predictive values were calculated for renal RLD from 6 to >10 mm. The left kidney was longer in 56%, whereas the right kidney was longer in 37%; their lengths were equal in 8%. For children at all ages, a left kidney longer than the right by ≥10 mm or a right kidney longer than the left by ≥7 mm gave a PPV for DMSA abnormality of 79% and 100%, respectively. In children older than 4 years, if the right kidney was longer by ≥7 mm or if the left kidney was longer by ≥10 mm, the PPVs for DMSA abnormality were 100% and 63%, respectively. In children younger than 4 years, when the right kidney was longer by ≥6 mm or the left was kidney longer by ≥10 mm, the PPV were 86% and 100%, respectively. Thus, children with a right kidney longer than the left by even <10 mm is a reliable predictor of an abnormal DMSA scan.

Aim: Post-streptococcal glomerulonephritis (PSGN) is a frequent cause of acute nephritis in children. Numerous studies have described PSGN in high-risk populations yet few data describing PSGN in a low-incidence population exist. This study aimed to describe the epidemiology, clinical manifestations, diagnosis, complications and outcomes of PSGN in an urban Australian population.Methods: A 16-year retrospective review of case notes and laboratory data was conducted at a tertiary Sydney paediatric hospital.Results: Thirty-seven children were treated for PSGN with a mean age of 8.1 years (range 2.6-14.1 years). Twenty-eight subjects (75.7%) had a history of a recent upper respiratory tract or skin infection. Hypertension and/or oedema was present in 29 subjects (78.4%). Streptococcal pharyngitis was identified as the likely source in 17 subjects (45.9%). Skin infections occurred less frequently. Antibodies against streptolysin O, streptokinase or deoxyribonuclease B were elevated when a single titre was measured in 35 subjects (94.6%). Thirty subjects (81.1%) developed renal impairment (median peak creatinine, 95 mu mol/L, range 39-880 mu mol/L). No correlation was demonstrated between peak creatinine, age, ethnicity, streptococcal titres and serum complement levels. The mean length of admission was 8.2 days. Seven subjects (18.9%) had a complicated course with three subjects requiring dialysis. Only one subject has ongoing renal dysfunction.Conclusion: Significant differences are seen in a low-incidence urban Australian population with PSGN when compared with endemic or epidemic disease in high-risk populations. The higher rates of complications that were seen compared with previously studied populations need further clarification.

Moyamoya disease (MMD) is an idiopathic progressive disorder associated with stenosis or occlusion of the cerebral vasculature with particular involvement of the circle of Willis and the arteries that feed it. Renal artery lesions and renovascular hypertension (RVH) in MMD have been described by many authors. Captopril renography is a sensitive screening investigation for RVH in adults and children. Basal/acetazolamide stress brain perfusion SPECT with Tc-99m HMPAO performed, in MMD can disclose regions of decreased cerebral perfusion and cerebrovascular reserve, which can be improved by revascularization surgery.

The letter by Sanchez-Bayle et al 1 states that the administration of hypotonic saline to children with gastroenteritis is not, in their view, associated with an increased risk of hyponatraemia. This is in …

Background. The major cause of late graft failure in adolescent kidney transplant recipients is thought to be nonadherence with medications. Delaying transplantation in adolescents may lead to improved adherence but at the cost of longer time on dialysis. To determine if waiting time on dialysis is a risk factor for graft survival in adolescents, we compared the outcomes of kidney transplants according to age and time on dialysis.Methods. We analyzed data from the Australian and New Zealand Dialysis and Transplant Registry on 2,739 primary kidney transplants performed between 1980 and 2004 in recipients less than 30 years old. Outcomes according to age at transplantation and waiting time were analyzed by Kaplan-Meier curves, log-rank tests, and Cox proportional hazard tests.Results. Overall five- and 10-year graft survival rates were significantly worse in adolescents (65% and 50%, respectively) compared to recipients aged two to 10 years (74% and 58%) and 20 to 29 years (72% and 57%). Waiting time on dialysis was an independent risk factor for failure of living donor grafts in adolescents (hazard ratio 0.53, P=0.03). Five-and 10-year graft survival of preemptive grafts in adolescents were 82% and 70%, respectively, which were similar to survival rates of preemptive grafts in other age groups.Conclusions. Reduced graft survival rates in adolescent recipients are not seen after preemptive transplants. Preemptive grafts are associated with a 50% reduction in the risk of graft failure. Delaying transplantation in adolescents may expose them to increased risk of poorer outcomes.

Bone marrow transplant nephropathy (BMTN) classically presents more than 100 days after transplantation as an acute nephritis with hypertension, azotaemia and anemia that usually results in end stage renal failure (ESRF). The risk of developing BMTN may be greater with the use of more intensive chemotherapy and higher total body and tumor bed irradiation. Cis-retinoic acid (RA) may further increase the risk of developing BMTN. Here, we report the cases of two children who developed typical clinical and biochemical features of BMTN. They were both treated for stage IV neuroblastoma with chemotherapy, bone marrow transplant (BMT) conditioning that included total body irradiation and RA therapy after BMT, although the patient in case 1 had established renal insufficiency prior to the commencement of RA. Renal biopsy of these children showed classical BMTN histology, and the renal manifestations progressed quickly; the patient in case 1 became dialysis dependent by 1 year post-bone marrow transplant. Recently, RA has been added to the post-BMT therapy in children with stage IV neuroblastoma. The occurrence of BMTN in two children treated with RA in our unit is unlikely to be coincidental. Although RA has been shown to confer a significant survival advantage in this disease, animal studies and a previous case report have suggested it could increase the toxic effects of chemotherapy and renal irradiation. It is likely that RA contributed to the deterioration in renal function in these patients.

The use of ambulatory blood pressure monitoring (ABPM) can improve the accuracy of paediatric BP measurement and may better correlate with end-organ injury than office BP measurement. However, the interpretation of ABPM may be influenced by several variables. We sought to ascertain the agreement among three paediatric nephrologists when reporting 92 ABPM sessions performed on patients aged 5 to 18 years. All three nephrologists were in agreement on the presence or absence of hypertension in 64% of cases. They were less likely to concur about records where hypertension was borderline or if the ABP record contained fewer BP readings. These results highlight the need for evidence-based consensus regarding the interpretation of ABPM in children.

Recently published reports suggest that the combination of aminoglycosides with ceftazidime may increase the risk of renal disease in cystic fibrosis. We describe a case of unusually severe acute tubular necrosis occurring in an adolescent with cystic fibrosis receiving i.v. gentamicin plus ceftazidime and discuss the possible mechanisms.

AIMS:To determine whether the risk of hyponatraemia in children with gastroenteritis receiving intravenous (IV) fluids is decreased by the use of 0.9% saline.METHODS:A prospective randomised study was carried out in a tertiary paediatric hospital. A total of 102 children with gastroenteritis were randomised to receive either 0.9% saline + 2.5% dextrose (NS) or 0.45% saline + 2.5% dextrose (N/2) at a rate determined by their treating physician according to hospital guidelines and clinical judgement. Plasma electrolytes, osmolality, and plasma glucose were measured before (T(0)) and 4 hours after (T(4)) starting IV fluids, and subsequently if clinically indicated. Electrolytes and osmolality were measured in urine samples. Results were analysed according to whether children were hyponatraemic (plasma sodium <135 mmol/l) or normonatraemic at T(0).RESULTS:At T(0), mean (SD) plasma sodium was 135 (3.3) mmol/l (range 124-142), with 37/102 (36%) hyponatraemic. At T(4), mean plasma sodium in children receiving N/2 remained unchanged in those initially hyponatraemic (n = 16), but fell 2.3 (2.2) mmol/l in the normonatraemic group. In contrast, among children receiving NS, mean plasma sodium was 2.4 (2.0) mmol/l higher in those hyponatraemic at baseline (n = 21) and unchanged in the initially normonatraemic children. In 16 children who were still receiving IV fluids at 24 hours, 3/8 receiving N/2 were hyponatraemic compared with 0/8 receiving NS. No child became hypernatraemic.CONCLUSIONS:In gastroenteritis treated with intravenous fluids, normal saline is preferable to hypotonic saline because it protects against hyponatraemia without causing hypernatraemia.

A 6 year old boy presenting with a five month history of fever, lethargy, and anorexia, was found to have hepatitis B associated membranous glomerulonephropathy and nephrotic syndrome. After two months treatment with oral lamivudine, his proteinuria cleared and serum albumin and aminotransferases normalised, associated with disappearance of hepatitis B e antigen (HBeAg) and appearance of anti-HBeAg antibodies. After 12 months, without side effects, lamivudine was discontinued. He remains well 11 months off treatment.