|Year : 2020 | Volume
| Issue : 2 | Page : 92-105
Selected abstracts of the 32nd annual conference of the Indian society of pediatric nephrology, 12–13 december 2020
|Date of Web Publication||31-Dec-2020|
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
. Selected abstracts of the 32nd annual conference of the Indian society of pediatric nephrology, 12–13 december 2020. Asian J Pediatr Nephrol 2020;3:92-105
|How to cite this URL:|
. Selected abstracts of the 32nd annual conference of the Indian society of pediatric nephrology, 12–13 december 2020. Asian J Pediatr Nephrol [serial online] 2020 [cited 2021 Jan 26];3:92-105. Available from: https://www.ajpn-online.org/text.asp?2020/3/2/92/306290
| S1 Fluid overload in critically ill patients: Challenging outcomes|| |
M. V. Patil, S. B. Kurbeit, G. Nair, J.
Department of Pediatrics and Pediatric Intensive Care Unit, KLES Dr. Prabhakar Kore Hospital and Medical Research Centre, Belagavi, Karnataka, India
Introduction: Parenteral fluids are the second most common intervention on acutely ill patients (after oxygen) in pediatric intensive care units (PICUs). Fluid overload (FO) has been associated with severe morbidity in patients with acute kidney injury (AKI) and acute lung injury. Chest radiography, ultrasonography, echocardiography, and impedance cardiography are noninvasive methods that detect fluid overload in PICU setting; however, in a developing country like India, their use becomes cumbersome, requires expertise, and is economically burdening. Documenting the daily intake–output and serial body weight measurements becomes an ideal method in such settings.
Methods: This study, conducted from January 2016 to December 2016, was designed to find the incidence of FO at 24 and 48 hr of admission in critically ill children admitted in the PICU in a single center and to determine the outcome of FO. FO was calculated by the formula: % FO = ([total fluid (L) – total fluid out (L)]/admission weight [kg]) × 100.
Results: Of 125 critically ill children studied, 59.20% were boys and the boy-to-girl ratio was 1.45:1. The most common age group was =3 years (36.8%) and the mean age was 6.2 ± 4.9 years. Septicemia (44%) was the cause of admission in 44% of children. At 24 hr, 83 patients (66.4%) had FO of <10%. However, significant FO of >10% was noted in 6.4%. At 48 hr, 69 (55.2%) children had some degree of FO. The incidence of significant FO at 48 h was 0.81%. Significantly higher number of children (25%) with FO were aged between 3 and 5 years (P = 0.037). Adverse outcome was significantly associated with FO (P = 0.027). Significantly higher number of children (76.92%) with FO at 48 hr had a longer duration of ICU stay (8–14 days) (P = 0.020). Complications of AKI were noted in 16.8%. No association was found between AKI and FO (P = 0.416) and between mean oxygen support days and ventilator support days (P > 0.05).
Conclusion: A considerable subset of children admitted to the PICU is at risk of significant FO (=10%). Weight-based definitions of FO are useful in defining FO in a broad PICU patient population and provide evidence for a more practical weight-based definition of FO that can be used at the bedside, especially in a developing country and resource-limited setting.
| S2 Validation of the 4-hr voiding observation in Indian neonates|| |
R. W. Thergaonkar, V. Bhat2, A. Z. Jamal2, S. Awasthi3
1Department of Pediatrics, INHS Asvini, Mumbai, Maharashtra, Departments of 2Pediatrics and 3Radiology, INHS Kalyani, Visakhapatnam, Andhra Pradesh, India
Introduction: The 4-hr voiding observation (FHVO) is an important noninvasive urodynamic test for infants. There is a need to adapt the test protocol for the use in India and there is a paucity of normative data in neonates.
Methods: This was an observational study from a secondary care hospital in South India catering to children of government employees with nation-wide representation conducted from August 2018 to August 2020. The study was aimed to modify the FHVO for use in Indian neonates and generate normative data for term Indian neonates. Term appropriate-for-gestational age neonates were included on day 4–14 of life. We excluded neonates with perinatal asphyxia, sepsis, congenital anomalies of the kidney and urinary tract, neural tube defects, weight loss more than 10% since birth or more than 3% in the previous 24 hr, passing urine less than four times the previous day or not passing urine on the day of the test, phototherapy in the last 12 h, and inadequate breastfeeding reported by mother or staff. FHVO was performed using the following modifications: (a) direct observation of voids instead of gossip strip, (b) measurement of postvoid residue (PVR) by ultrasonography using two formulae within 5 min of voiding.
Results: A total of 106 neonates were enrolled. Median (interquartile range) of important test outcomes is as follows: number of voids 1 (1–2), voided volume 15 (10–21) ml, maximum voided volume (MVV) 16.4 (11–24) ml, PVR (formula 1): 2.37 (1.28–4.08) ml, PVR (formula 2): 3.25 (1.71–5.65) ml, functional bladder capacity (FBC) (formula 1): 19.5 (12.78–25.96) ml, FBC (formula 2): 20.77 (13.48–27.81) ml, PVR% (formula 1): 12.90 (7.92–22.81), PVR% (formula 2): 17.33 (10.95–29.02) ml, and diuresis: 1.76 (0.81–2.84) ml/kg/hr. There were 2.9% (standard error of proportion 1.3%) interrupted voids. Phototherapy received more than 12 hr before the testing was significantly associated with lower PVR; no significant effects of gender and delivery by cesarean section were observed. There was a significant correlation between test outcomes of both MVV and PVR% with diuresis and number of voids; linear regression yielding models for MVV and PVR% are as follows: MVV = 13.8205 + 7.9323 × Diuresis - 7.2425 × Number of voids (r2 = 0.77), PVR% (formula 1) = -3.4622 - 2.646 × Diuresis + 13.8993 × Number of voids (r2 = 0.43), PVR% (formula 2) = 1.5395 - 2.1622 × Diuresis + 11.7707 × Number of voids (r2 = 0.43).
Conclusion: We report normative data on the FHVO for Indian neonates. Gender and mode of delivery do not affect the test. Phototherapy administered more than 12 hr before the test is associated with lower PVR. MVV and PVR% correlate with urine output and number of voids; linear regression models are reported.
| S3 The association of 25-hydroxyvitamin D and first episode of culture-positive urinary tract infection in children between 1 and 5 years of age: A case–control study|| |
R. Divya, S. Chidambaram, U. Pasupathy, G. Sangeetha
Department of Pediatrics, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
Introduction: Urinary tract infection (UTI) is one of the common bacterial infections in infants and young children. The incidence varies with age, with a male:female ratio being 3–5:1 during infancy. Beyond 1 year, there is female preponderance with a male-to-female ratio of 1:10. vitamin D has antibacterial and immunomodulatory properties, besides a role in calcium and phosphorus homeostasis. vitamin D plays a cardinal role in immune regulation by the induction of human genes for cathelicidin cAMP. Considering the importance of identifying the risk factors associated with UTI and preventing complications, we did a study to determine the association of serum vitamin D levels and UTI in children.
Methods: This study was aimed to determine whether vitamin D deficiency is one of the risk factors for the first episode of UTI in children. 60 children with first episode of culture-positive UTI and 63 age- and sex-matched healthy controls, admitted for elective surgery without any obvious signs of rickets or genitourinary abnormalities, were enrolled. 25-hydroxyvitamin D levels were assessed by Unicel Dxl chemiluminescent immunoassay system. vitamin D levels <12 ng/mL were considered deficient, between 12 and 20 ng/mL as insufficient, and >20 ng/mL as sufficient (IAP Guidelines). Statistical analysis was done using Chi-square test and Pearson's correlation test.
Results: On analyzing vitamin D levels between the cases and controls, the mean value of vitamin D was 21.6 ± 8.9 in cases and 31.31 ± 10.77 in controls (P = 0.01). In the study group, 6 were vitamin D deficient (10%), 27 had insufficient (45%), and 27 had sufficient levels (45%). In the control group, 10 had insufficiency (15.9%) and 53 had sufficient levels (84.1%). Out of 60 cases, 39 were in the age group of 1–3 years (65%) and 21 were between 4 and 5 years (35%). Among 1–3 years, 23 cases were boys (38.3%). Escherichia coli was the most common organism isolated among the culture-positive cases, accounting to 57 cases (95%). One of each proteus, Acinetobacter and Morganella were isolated. The most common symptomatology was fever (91.1%) seen in 55 cases, whereas 27 had crying micturition (45%), 19 had vomiting (31.6%), and 17 had increased frequency of micturition (28.3%). Among the cases, 14 showed pyuria (23.3%) and 7 showed nitrate positivity (11.6%) in urine analysis. Leukocytosis was seen in 50% of cases (n = 30). In 58.4% of cases with abnormal ultrasonography, the most common finding was cystitis. There was a negative correlation of serum vitamin D levels with leukocyte counts (-0.07) and polymorphs (-0.15).
Conclusions: vitamin D levels were significantly lower in cases compared to controls. Since vitamin D deficiency influences bladder wall immunity, it is postulated that Vitamin D deficiency could be a risk factor for UTI. vitamin D supplementation could be a simple intervention of immune defense against UTI.
| S4 Assessment of overhydration in children on continuous ambulatory peritoneal dialysis by bioimpedance vector analysis: A longitudinal observational study|| |
S. Reddy, A. Vasudevan, A. Iyengar
Department of Pediatric Nephrology, St. John's Medical College Hospital, Bengaluru, Karnataka, India
Introduction: Detecting overhydration in children on chronic ambulatory peritoneal dialysis (CAPD) is critical as it contributes to cardiovascular morbidity and mortality. However, precise clinical assessment of overhydration is challenging. Bioimpedance vector analysis (BIVA) is a bedside body composition tool that can estimate overhydration with a potential role of guiding the clinician on fluid management. This study aimed to longitudinally assess and compare the overhydration status detected using clinical assessment and BIVA in children on CAPD.
Methods: A longitudinal observational study was undertaken in clinically stable children (aged 4–18 years) on CAPD (minimum duration of 6 months) from May 2017 to January 2020 at the pediatric chronic kidney disease clinic of a tertiary hospital. Presence of overhydration was assessed by clinical signs, bioimpedance measures, and BIVA at enrollment and 3 and 6 months of follow-up. Modifications to CAPD prescriptions and antihypertensive medications were based on the clinical assessment only. Children were categorized as having clinical overhydration if they fulfilled 2 of 3 criteria of weight gain (>7% of body weight), uncontrolled hypertension (office blood pressure =95th centiles, despite being on antihypertensive medications), and presence of signs of fluid overload. Based on a normative reference R-Xc graph, derived from Z-scores of 20 healthy controls, bioimpedance vectors were plotted. The position of the vector in the left lower quadrant beyond the 95% tolerance ellipse was regarded as overhydration. Differences in the longitudinal vector displacement were analyzed using Hotelling's T2 test.
Results: Twenty-six children (18 boys, median age 9.5 (4, 16) years) on CAPD for 21 (12, 72) months were enrolled. Nonglomerular etiology was noted in 69% of cases, and 58% had residual kidney function. At enrollment, the proportion of children with overhydration assessed clinically and by BIVA was 34.6% and 30.7%, respectively. There was poor agreement between measures of overhydration by clinical assessment and BIVA at all three time points. Among those detected to be overhydrated at enrollment, 9/11 (82%) and 4/9 (44%) remained overhydrated at 6 months by BIVA and clinical assessment, respectively. The BIVA plots on the reference R-Xc graph [Figure 1] revealed a significant difference in the vector displacement toward the quadrant of overhydration at all time points, with the maximum difference seen between enrollment and 6 months (T2 = 32.58, P < 0.001).
Conclusion: In children on CAPD, there is poor agreement between measures of overhydration detected clinically and by BIVA. Longitudinal vector plots over 6 months reflect persistence of overhydration in a majority, as compared to clinical assessment. Further studies to explore the utility of BIVA in guiding a clinician with fluid management in these children are warranted.
| S5 Association of urine microalbuminuria with severity of dengue fever in children: A cross-sectional study|| |
S. Deepika, G. Sangeetha, A. Prasath, P. Ramachandran
Department of Pediatrics, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
Introduction: Dengue fever (DF) is a systemic illness which often strains the healthcare system during epidemics. If a reliable predictor of its severity can be identified, it will enable us to monitor the “at-risk children” more meticulously so that our limited resources can be wisely used. Presence of microalbuminuria is recognized as a useful early predictor of vascular complications of diabetes mellitus. Since the complications of DF are also due to vascular involvement, an attempt was made to explore if the same microalbuminuria can be used as a harbinger of severe dengue (SD). This study was aimed to identify an association between microalbuminuria and severity of DF so as to explore if it can be used as a screening tool for assessing the severity.
Methods: A cross-sectional prospective study of 234 dengue children admitted in the pediatric ward and pediatric intensive care unit from August 2018 to March 2020 was done. DF was classified as per the WHO criteria as probable dengue, dengue with warning signs (DWS), and SD. Urine samples were sent for all patients on or after the 4th day of fever for estimation of microalbuminuria. Daily clinical assessment was done for all the admitted children till discharge. Association between microalbuminuria and various categories of DF was analyzed using statistical tools.
Results: Among the 234 children enrolled, DF was diagnosed in 37.6% (n = 88), DWS in 52.9% (n = 124), and SD in 9.4% (n = 22). Significant microalbuminuria (>30 mg/g of creatinine) was present in 26 children. 10 cases of SD (45.5%) and 16 cases (12.9%) of DWS had microalbuminuria (P = 0.0001). None of the 88 children with DF had significant microalbuminuria.
Conclusion: Significant microalbuminuria has an association with severe dengue; it can be used as a marker to screen all children admitted with DF. Microalbuminuria has good negative predictive value; children with a negative microalbuminuria done on 4th day of illness can safely be excluded from close monitoring. Early identification of such cases and aggressive fluid management with close monitoring would improve the outcome and reduce the days of hospitalization.
| S6 Prevalence of congenital anomalies of kidney and urinary tract in children|| |
M. Kadlimatti, M. Patil, S. B. Kurbet
Department of Pediatrics, KLES Dr. Prabhakar Kore Hospital and Medical Research Centre, Belagavi, Karnataka, India
Introduction: Congenital anomalies of kidney and urinary tract (CAKUT) are a group of abnormalities affecting the kidneys and other structures of the urinary tract. This study was aimed to find the prevalence of CAKUT along with other associated anomalies and to assess the degree of renal dysfunction.
Methods: This cross-sectional study was conducted at a tertiary care center in Karnataka over 1 year. Newly diagnosed CAKUT cases were enrolled and were evaluated for CAKUT and other associated anomalies, and renal dysfunction was evaluated based on Acute Kidney Injury Network (AKIN) criteria.
Results: During the study period, there were 7893 admissions. Among them, 81 cases were diagnosed to have CAKUT, but six cases (0.07%) were previously diagnosed cases of CAKUT and excluded; thereby, the diagnosis of CAKUT was confirmed in 75 cases. Hence, the prevalence of CAKUT was 0.95% or 9.5 per 1000 children. Hydronephrosis with pelviureteric junction obstruction (PUJO, 25.3%) was the most common CAKUT, followed by hypospadias (20%). Other associated anomalies were noted in 8% of the children. Anorectal malformation was the common associated malformation noted among 5.3% of the children. Based on the AKIN criteria, Stage I renal function was noted in 10.7% of the children and Stage II in 9.3% of the children. Majority of the study subjects were male (89.3%) and most of the children belonged to the age group <1 year (57.3%). Gestational diabetes mellitus and pregnancy-induced hypertension were the common risk factors noted in 10.7% each. Majority of the children (64%) underwent surgical intervention, and the majority of the children improved (69.3%).
Conclusions: The prevalence of CAKUT in children aged between 1 month and 18 years is 9.5 per 1000 children. Hydronephrosis is the most common anomaly due to PUJO and hypospadias.
| S7 Evaluation of public knowledge of chronic kidney disease in children using a validated questionnaire: A cross-sectional study|| |
R. Kurade, S. Ekambaram, V. Raman, P. Kumar, T. Gunumuthu, N. B. Rangaswamy, D. Ranganathan
Department of Pediatrics, Mehta Multispeciality Hospital, Chennai, Tamil Nadu, India
Introduction: Prevalence of pediatric chronic kidney disease (CKD) is 18 per million children globally. Prevention and retarding progression of CKD by early diagnosis and management are the ideal strategies for resource-limited countries like India. To establish guidelines for education of the community, it is essential to study the existing knowledge and knowledge lacunae in childhood renal health, disease, and prevention. Determining the public knowledge of CKD also provides guidance to health professionals, researchers, and kidney health organizations when preparing blueprints for education campaigns. This study was designed to determine the knowledge of CKD in the Chennai district using newly developed and validated questionnaires and to determine the potential predictors of CKD knowledge among the public.
Methods: A draft of CKD knowledge questionnaire was generated through literature review by four pediatric nephrologists and two research personnel. The questionnaire was divided into eight sections and included 42 evidence-based questions. Methodological validity was ensured by seven questions with negative response as correct response. Fifty adults assessed face validity including phrasing, clarity, and formatting. Two questions were eliminated after face validation. Reliability was assessed using kappa. A cross-sectional survey of the questionnaire was administered with online Google Forms. Those who completed higher school education were included. Medical, allied health personnel and those with kidney disease were excluded. Bivariate analyses were performed using one-way ANOVA and independent t-tests, as appropriate, to compare the effect of participants' sociodemographic characteristics on CKD knowledge score. Multivariable linear regression model was constructed to predict knowledge scores based on the potential predictor variables.
Results: The online survey was conducted between September and October 2019. Among 1222 who undertook the survey, 39 were excluded. Reliability of questionnaire measured by kappa was 0.86, suggestive of strong consistency when administered 3 weeks apart. Mean (±standard deviation [SD]) age of the respondents was 24 (±5) years. Major source of knowledge was from the internet (28.2%) followed by doctors (27.2%). Mean knowledge score (±SD) of the public was 20.87 (±6.86) out of 40. Knowledge of kidney diseases in children in the various domains were as follows: physiology of kidney 62.3%, prevention of kidney disease 58.9%, treatment modalities of CKD in children 59.6%, signs and symptoms of childhood CKD 49.8%, the fact that children could be prone to kidney problems 43.8%, diagnostic tests for kidney disease 43.3%, and common kidney disorders 46.1%. The multivariate analysis found higher knowledge scores associated with age, gender, marital status, and those with relative suffering from kidney problems with an R2 of 0.07 and P < 0.05.
Conclusion: The internet is a major source of knowledge. Hence, we have to make quality and structured content regarding pediatric kidney disease available on the internet. Age, gender, marital status, and those with relative suffering from kidney problems were influential factors on knowledge scores. Overall knowledge about childhood kidney problems in the educated population was 52%. Hence, we need to increase awareness about kidney disease which will help in reducing morbidity/mortality in children and help to live a healthy adult life.
| S8 The prevalence of hypertension in frequently relapsing and steroid-dependent nephrotic syndrome in a tertiary care hospital in south India|| |
B. R. Ritesh, M. V. Patil
Department of Pediatrics, KAHER's Jawaharlal Nehru Medical College, Belagavi, Karnataka, India
Introduction: Nephrotic syndrome is the most common glomerular disorder in children. The children who are diagnosed with steroid-dependent nephrotic syndrome (SDNS) and frequently relapsing nephrotic syndrome (FRNS) have more chances of developing hypertension, leading to cardiovascular morbidity. Ambulatory blood pressure monitoring (ABPM) is the gold standard for noninvasive blood pressure (BP) monitoring. This study was undertaken to find the prevalence of hypertension in patients diagnosed with FRNS and SDNS using ABPM and its association with cardiovascular morbidity.
Methods: Children between 1 and 18 years of age diagnosed to have FRNS and SDNS who visited the hospital between June 2019 and June 2020 were enrolled. It was a prospective observational study. Each patient was monitored for BP via ABPM, which is approved by the Association for the Advancement of Medical instrumentation, British Hypertension Society, and European Society of Hypertension for Children. The children who were detected to have hypertension were further evaluated with echocardiography to look for left ventricular hypertrophy (LVH) by Devereux formula. All children were assessed for growth retardation. Data were analyzed using R software R Core team, R Foundation for Statistical Computing, Vienna, Austria; version 3.6.1, released 2014 and Chi-square test.
Results: Totally, 49 children were included in our study with a mean age being 8.15 ± 3.85 years and a male-to-female ratio of 1.72:1. Among the study subjects, 59.2% were SDNS and 40.8% were FRNS. Prevalence of masked and ambulatory hypertension was 61.2%. Prevalence of hypertension in patients with SDNS and FRNS was 55.2% and 70.0%, respectively. Many hypertensive patients (60%) had LVH. The chances of developing LVH in hypertensive subjects who are at a risk of end-organ damage, i.e., the children with a BP load >50%, were 40 times and 15 times higher in patients diagnosed with SDNS and FRNS, respectively. Growth retardation was seen in 15 (33%) patients. 11 (37.9%) SDNS cases and 4 (20%) FRNS patients had growth retardation. Among the patients with SDNS, the mean steroid-dependent dosage of the patients with growth retardation was higher (0.21 mg/kg/day) in contrast to the patients without growth retardation in whom the mean steroid-dependent dosage was 0.17 mg/kg/day.
Conclusions: The prevalence of hypertension in children diagnosed as SDNS and FRNS was 61.2% using ABPM. Children with hypertension at a risk of end-organ damage (BP load of >50%) were significantly associated with development of LVH.
| S9 Usefulness of tubular reabsorption of phosphate as a surrogate marker of mineral bone disease in chronic kidney disease children and its association with dietary phosphate intake|| |
R. Pal1, I. Agarwal1, V Srinivasan1, P Christudoss2, V Natarajan2
1Division of Pediatric Nephrology, Christian Medical College, 2Department of Biochemistry, Christian Medical College, Vellore, Tamil Nadu, India
Introduction: The association of hyperphosphatemia with bone diseases, vascular calcification, and cardiovascular mortality is well known. Serum phosphate is a late marker of mineral bone disorders (MBD), while fibroblast growth factor-23 (FGF-23), a phosphaturic hormone, rises early. Tubular handling of phosphate is best studied by evaluating tubular reabsorption of phosphate (TRP). Relating it to dietary intake and markers of disease progression will provide useful information on management. This study was aimed to study the relationship between TRP and dietary phosphate intake and its association with MBD and progression of chronic kidney disease (CKD).
Methodology: Sixty-six children aged between 1 and 18 years with CKD stage 2–5 were recruited. Serum phosphorus, 24-hr urine phosphorus and creatinine, parathormone (PTH), 25-hydroxy-vitamin D, and FGF-23 were measured; estimated glomerular filtration rate (eGFR) and TRP were calculated. Dietary phosphate intake was calculated using a 3-day recall method. The data were statistically analyzed.
Results: Median age was 11.2 years; males predominated (86.4%). Hyperphosphatemia was prevalent in 23 (34.8%). Mean phosphate level was higher in stage 4 (5.1 mg/dl) and lowest in stage 2 (4.7 mg/dl). Mean TRP was significantly higher in stage 2 (90.3%) compared to stage 5 (65.0%) (P < 0.001; r = 0.583). TRP correlated well with increase in PTH (P = 0.003, r = -0.48) and fall in eGFR, but there was a weaker association with FGF-23 (P = 0.076, r = -0.008). Using multiple linear regression model (r2 = 0.54), with PTH as the dependent variable, TRP (β = -0.371, P = 0.010) and 25-hydroxy-vitamin D (P = 0.051, β = -2.009) showed a strong correlation. Dietary phosphate intake did not show a significant correlation with serum phosphate level (P = 0.08, r = -0.228) or TRP (P = 0.773, r = 0.046). The mean serum phosphate level did not differ between those on vegetarian (15.8%; P = 0.060) and nonvegetarian diet (84.2%; P = 0.508). FGF-23 was shown to be the earliest detectable abnormality, followed by TRP; phosphate was the last to rise.
Conclusion: Serum phosphate is a late marker of MBD in CKD children. Although FGF-23 rises early, TRP may be recommended as an economical surrogate marker, which correlates well with eGFR and PTH levels. Dietary intake may not be an accurate measure of serum phosphate concentration.
| S10 Functional bladder capacity in children with primary monosymptomatic nocturnal enuresis|| |
A. Kumar1, K. Kapoor1, K. C. Aggarwal1, R. Chandra2, A. Kumar3, R. Gera1
Departments of 1Pediatrics, 2Radiology and 3Urology, Vardhaman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
Introduction: The pathophysiology of nocturnal enuresis (NE) is complex. Nocturnal polyuria with low overnight vasopressin levels and nocturnal polyuria with low functional bladder capacity (FBC) are two archetypes which are the basis of the management of primary monosymptomatic nocturnal enuresis (PMNE). This study was aimed to estimate the FBC by ultrasonography of children aged 5–15 years with PMNE and to compare with maximal voided volume by 48-hr frequency volume charts and voided volumes by uroflowmetry.
Methods: A prospective observational study was carried out in the pediatric outpatient department of tertiary care teaching hospital in New Delhi, India, from September 2018 to February 2020. All children, aged 5–15 years, presenting with NE were screened. Children with enuresis with no other lower urinary tract symptoms were defined as PMNE and were enrolled in the study. Those with secondary enuresis, daytime lower urinary tract symptoms, signs of underlying anatomical or neurogenic causes, growth retardation, kidney disease, thyroid disorder or epilepsy, and genitourinary anomalies and abnormal dipstick tests were excluded. Enuresis, its subtypes, and lower urinary tract terminology were defined as per the ICCS Standardized Terminology. A detailed history including comorbidities and physical examination of abdomen, spine, and genitalia was recorded in a predesigned pro forma. 48-hr daytime bladder diary, urine routine microscopy, and ultrasonographic scan (USS) of the kidneys and bladder to record FBC, bladder wall thickness, and postvoid residual urine volume were done in all children. Low FBC was defined as <65% of expected bladder capacity. Uroflowmetry was done to record flow patterns, voided volumes and peak flow rate Curves with a voided volume of >50 ml urine were considered valid for analysis.
Results: 67 children with NE were screened. 46 cases with PMNE were enrolled in the study. Mean age of the children in the study was 9.6 ± 2.0 years; 28 were boys and 18 were girls with a male-to-female ratio of 1.5:1; 73.9% had severe enuresis (>5 nights per week) and 26% had a family history of enuresis. Comorbidities such as constipation were present in 39%, snoring in 47.8%, behavioral problems in 8.7%. 37 children out of 46 (80.4%) had low FBC. Uroflowmetry studies were done in 26 children. 20 children had normal bell-shaped curves, 1 child had invalid study as the voided volume was <50 ml, and 5 children had abnormal study. A weak positive correlation (r = 0.255) was found between maximal voided volume recorded by bladder diary and FBC by ultrasound. A weak positive correlation (r = 0.191) was found between maximal voided volume recorded by bladder diary and voided volumes by uroflowmetry.
Conclusion: Children with PMNE have low FBC, and 48-hr daytime bladder diary is a reliable tool to evaluate bladder capacity in these children.
| S11 Hypertension in children with infrequently relapsing nephrotic syndrome: A longitudinal observational study|| |
M. Fathima1, A. Saha1, S. Chopra1, A. Das1, A. Raj2, D. Bhatt3
1Division of Pediatric Nephrology, Department of Pediatrics, Lady Hardinge Medical College and Kalawati Saran Children's Hospital, 2Department of Cardiology, Lady Hardinge Medical College and Kalawati Saran Children's Hospital, 3Division of Pediatric Cardiology, Department of Pediatrics, Lady Hardinge Medical College and Kalawati Saran Children's Hospital, New Delhi, India
Introduction: Hypertension in children with infrequently relapsing nephrotic syndrome (IFRNS), especially end-organ damages such as left ventricular hypertrophy (LVH), concentric geometry, and hypertensive retinopathy, are not well studied. We intended to identify the proportion of IFRNS children having hypertension during relapse and to study the association between hypertension with dyslipidemia and hypertensive retinopathy during relapse and left ventricular mass (LVM) index at 4 weeks of steroid therapy.
Methods: Children aged 1–12 years with IFRNS during relapse (off steroid and antihypertensive medications for a minimum of 3 months) were included. With an estimated prevalence of hypertension in IFRNS (P) of 25%, alpha error of 5%, acceptable absolute precision (e) of 10%, and 95% confidence interval, the sample size was 73; assuming 10% attrition, a total of 83 patients were recruited. All the subjects underwent blood pressure measurement, fundus examination, and blood and urine examination at relapse and at 4 weeks of steroid therapy during remission. In addition to the 2017 AAP guideline, hypertension was classified and compared using the 4th Report and the ESC-ESH guidelines. This study used a linear method of LVM estimation using Devereux and Reichekcube formula, LVM = 0.8 × 1.04 × ([interventricular septum, diastolic (IVSd) + left ventricular internal diameter, diastolic (LVIDd) + posterior wall thickness, diastolic (PWTd)]3 - LVIDd3) + 0.6. Relative wall thickness (RWT) was measured for concentric geometry (CG) at end diastole as RWT = IVSd + PWTd/LVIDd. Dyslipidemia in parents was diagnosed using the AACE 2017 guidelines.
Results: Of 83 cases enrolled, 32.5% developed hypertension during relapse (25.3% stage I and 7.2% stage II). The presence of hypertension in the first episode (63.0% vs. 19.6% P = 0.001) and previous relapses (87.5% vs. 37.8%; P = 0.001) was significantly associated with the development of hypertension in the current episode. History of hypertension among parents was present in 36.7% of the patients, of which 29.6% were in the hypertensive group and 7.1% as normotensive (P = 0.016). At 4 weeks of follow-up, 7.4% had hypertension of which 5.0% had a new onset and 2.3% had persistent hypertension (P < 0.001). Hypertensive retinopathy was present in 11.1% of the patients (P = 0.032) in the hypertensive group. Hypertension at relapse was seen more in persistent dyslipidemia at 4 weeks (48.4%) as compared to nondyslipidemia group (15.2%; P < 0.001). Thirty percent of the patients with hypertension at relapse and 31.5% with persistent dyslipidemia at 4 weeks of therapy had a positive family history of hypertension and dyslipidemia, respectively. CG was present in 28% of the hypertensive and 5.5% of the nonhypertensive group. The presence of CG in the nonhypertensive group may be because of masked hypertension. Near perfect agreement was observed in the classification of hypertension between the AAP 2017 and the 4th report (k = 0.963; P < 0.001) and also between the AAP 2017 and the ESC-ESH guideline (k = 0.973; P < 0.001) in our study. CG had a significant association with a lower serum albumin at the time of relapse (1.36 ± 0.30 vs. 1.58 ± 0.31; P = 0.045). Logistic regression analysis showed spot Up:Uc (odds ratio 1.61 [1.09–2.37]; P = 0.01) at relapse as a risk factor for hypertension.
Conclusion: Hypertension was seen in 32.5% of children with IFRNS during relapse. Early screening for target organ damage following hypertension will help in a timely initiation of response.
| S12 Predictive value of urinary neutrophil gelatinase-associated lipocalin in detecting severe acute kidney injury in critically ill pediatric patients|| |
A. Roy, S. Raut, M. Sarkar, M. Nandi
Department of Pediatrics, Pediatric Nephrology Wing, Medical College, Kolkata, West Bengal, India
Introduction: Neutrophil gelatinase-associated lipocalin (NGAL) is secreted in high levels into the blood and urine within 2 h of renal injury and can be used as an early biomarker for acute kidney injury (AKI). We aimed to find the positive and negative predictive values, sensitivity, and specificity of the urine NGAL (uNGAL) for the diagnosis of stage 2 and 3 AKI. Secondary objective was to find the relationship between NGAL with day 3 cumulative fluid balance, number of days pediatric intensive care unit (PICU) stay, and requirement of renal replacement therapy (RRT).
Methods: uNGAL was done by card test/chromatography method in patients admitted to the PICU with Pediatric Risk of Mortality III (PRISM III) score of >10 from March 2019 to February 2020.
Results: Out of total 39 patients admitted in the PICU with PRISM III score >10, 56.4% developed severe AKI (stage 2 and 3 AKI, defined by the AKIN criteria). Following a threshold value of day 1 uNGAL of 265.5 ng/ml, the sensitivity was 95.5%, specificity was 76.5%, positive predictive value was 84%, and negative predictive value was 86.7% to diagnose severe AKI in hospital course. The odds ratio for elevated uNGAL (>265.5 ng/ml) and association of >10% fluid overload on day 3 was 1.6 and association of requirement for RRT was 4.7. Peritoneal dialysis was the modality of RRT in all cases. Among the patients who required RRT, 71.4% did not have stage 2 or 3 AKI on day 1 as per the AKIN criteria. However, 80% of cases among those patients who did not have stage 2 or 3 AKI on day 1 as per the AKIN criteria had raised NGAL (>265.5) on day 1. The mean (±standard deviation) number of days of PICU stay in cases with raised NGAL (>265.5) was 10.4 (±6.2) in comparison to cases where NGAL was not raised (<265.5) being 11.8 (±10.6).
Conclusion: uNGAL can detect advanced stage of AKI early in the course of ICU stay in sick children and may be used as an add-on early biomarker for the detection of AKI due to its high sensitivity and predictive values. This information might provide a window to protect patients at risk of AKI from nephrotoxicity due to antibiotics, contrast and other interventions.
| S13 Feasibility and efficacy of sustained low-efficiency dialysis in critically ill children with severe acute kidney injury|| |
M. Yadav1, A. Sinha1, R. Lodha2, J. Sankar2, P. Hari1, A. Bagga1
Divisions of 1Nephrology and 2Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
Introduction: Severe acute kidney injury (AKI), common in critically ill patients in intensive care units (ICUs), often requires kidney replacement therapy (KRT). The optimal modality for KRT in patients with unstable vitals is unclear. While continuous KRT is preferred to intermittent hemodialysis, information on the role of sustained low-efficiency dialysis (SLED) in pediatric patients is limited to small retrospective series lacking objective estimates of fluid and solute clearance. Objectives were to examine the feasibility, efficacy, and safety of SLED in hemodynamically unstable critically ill patients, aged 1–18 years, requiring KRT for conventional indications.
Methods: This prospective unicenter study enrolled critically ill patients, aged 1–18 years, admitted to the ICU, with hemodynamic instability (=1 inotrope) and severe AKI requiring KRT. Patients weighing =8 kg or with mean arterial pressure <5th centile despite use of >3 vasopressors were excluded. The primary outcome was the proportion of patients in whom the first session of SLED was performed within 12 hr of KRT indication without premature (<6 hr) termination. Efficacy estimates included net ultrafiltration, equilibrated Kt/V, and urea reduction ratio. Other outcomes included changes in hemodynamic scores, % sessions with circuit clotting, % with clinical and biochemical adverse events (AEs), % requiring switch to alternative KRT modality, duration of ICU and hospital stay, and mortality. We also explored indices on point-of-care ultrasound and echocardiography.
Results: Over 18 months, 47 episodes of severe AKI merited KRT in 42 critically ill patients. Eighteen patients (72% boys; median age 104 months; weight 22 kg) were eligible and underwent 41 sessions of SLED. These patients had high pediatric index of mortality and vasopressor dependency indices (median 22.8 and 42.8, respectively). Except one, all patients were mechanically ventilated and/or had multiorgan dysfunction and sepsis. All eligible patients, except two, were initiated on SLED at <12 hr of indication (median 4.6 hr) for mean ± standard deviation session length of 387 ± 41 min. No session required premature termination. Therefore, SLED was feasible in 88.9% (95% confidence interval, 67.2%–96.9%) of patients. SLED sessions relied on temporary central venous catheters and pediatric hemodialysis tubings, usually primed with 5% albumin. Blood and dialysate flow rates were 3.7 ± 0.6 mL/kg/min and 241 ± 49.9 mL/min, respectively. No anticoagulation was required in 50% sessions; while circuit clotted in three sessions, all sessions were completed. SLED enabled net ultrafiltration of 4.0 ± 2.2 mL/kg/hr, urea reduction ratio of 57.7% ± 16.2%, and equilibrated Kt/V of 1.10 ± 0.52. Inotrope score, vasoactive inotropic score, and vasopressor dependency index did not change significantly. The chief AE was asymptomatic hypokalemia (46% sessions). SLED sessions led to significant decrease in the inferior vena cava diameter and increase in its distensibility, along with improved left ventricular function. The changes were weakly to moderately correlated with ultrafiltration. Fourteen (77.8%) patients died. Survival was associated with dialysis adequacy, assessed by ultrafiltration =25 mL/kg and eKt/V =1.
Conclusions: SLED is feasible, safe, and effective in enabling KRT in hemodynamically unstable pediatric patients with severe AKI. SLED enables adequate solute clearance and ultrafiltration. Large studies with more SLED sessions per patient should examine these associations prospectively.
| S14 Efficacy and safety of rituximab versus tacrolimus in frequently relapsing nephrotic syndrome: an open-label randomized controlled trial|| |
G. Mathew, A. Sinha, N. Grewal, A. Ahmed, P. Hari, A. Bagga
Department of Pediatrics, Division of Nephrology, ICMR Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, New Delhi, India
Introduction: Rituximab and tacrolimus effectively prevent relapses in children with frequently relapsing or steroid-dependent nephrotic syndrome who have failed multiple steroid-sparing therapies (difficult-to-treat disease). Information on the relative safety and efficacy of these therapies is limited.
Objectives: The primary objective was to compare, in patients with difficult-to-treat steroid-sensitive nephrotic syndrome administered intravenous rituximab or oral tacrolimus, the proportions of patients in sustained remission at 1-year follow-up. Secondary objectives included comparisons, at 6-month and 12-month follow-up, of the proportion of patients with frequent relapses and treatment failure (frequent relapses, steroid resistance, significant toxicity related to corticosteroids or intervention necessitating discontinuation of intervention, and =2 serious adverse events [AEs]), frequency of relapses, cumulative prednisolone requirement, the time to first relapse, AE related to intervention and prednisolone use, and changes in body mass index, height, and blood pressure standard deviation (SD) scores.
Methods: This single-center, open-label randomized clinical trial examined the noninferiority of rituximab (2 doses at 375 mg/m2 1 week apart) as compared to oral tacrolimus (0.1–0.2 mg/kg in two divided doses for 1 year) in patients, aged 1–18 years, with difficult-to-treat steroid-sensitive nephrotic syndrome (failure of =2 therapies). Patients were allocated 1:1 to the two groups using computer-generated random sequences stratified for disease severity and age while ensuring allocation concealment (CTRI/2018/11/016342).
Results: Of 108 patients screened, 41 patients were randomized and 40 included in modified intention-to-treat analysis; one patient allocated rituximab did not return for the infusion. Baseline characteristics were comparable (not shown). Outcomes, tabulated in [Table 1], indicate that noninferiority of rituximab in sustaining remission for 1 year was not demonstrated (predefined noninferiority margin, 20%). Frequent relapses were significantly more often in patients administered rituximab versus tacrolimus. Both groups showed considerable and comparable reduction in relapse rates and prednisolone usage (85% and 70%, respectively). Changes in anthropometry were similar between groups and improved significantly from baseline. Serious AEs were few and comparable in proportion between groups; chief AEs were infusion related with rituximab and gastrointestinal AE with tacrolimus.
Conclusions: In children with frequently relapsing nephrotic syndrome failing multiple steroid-sparing therapies, rituximab was not noninferior to tacrolimus in maintaining sustained remission. Compared to tacrolimus, rituximab was associated with increased risk of frequent relapses.
| S15 Incorporation of serum cystatin C with renal angina index for the prediction of acute kidney injury in critically ill children|| |
S. Aggarwal1, K. Afzal1, K. Alam2
Departments of 1Pediatrics and 2Biochemistry, Jawaharlal Nehru Medical College, Aligarh Medical University, Aligarh, Uttar Pradesh, India
Introduction: Pediatric acute kidney injury (AKI) is associated with high mortality among critically ill children. Creatinine-based detection has significant limitations in the pediatric population. Renal angina index (RAI) is a validated means of identifying and stratifying children at risk of AKI. The objective was to assess whether incorporation of serum cystatin C with RAI improves prediction of severe AKI in critically ill children.
Methods: This prospective cohort of 112 critically ill children admitted to the pediatric intensive care unit (PICU) from October 2018 to October 2020 was studied. Patients with KDIGO stage 2–3 AKI at admission, known CKD, serum bilirubin >5 mg/dL, or <72 hr PICU stay were excluded. RAI score was determined at PICU admission, and blood was collected for cystatin C estimation. Patients were followed for 7 days. Primary outcome measure was severe AKI by day 3. Area under the receiver operating characteristic curve (AUC) was calculated and compared for RAI and serum cystatin C.
Results: Mean (standard deviation) age of the study population was 66 (52) months; 52 (46.4%) were males. Sepsis (20.5%) and meningitis (17.8%) were the predominant diagnoses. Respiratory failure (25%) and shock (33%) were the primary indications for PICU admission. Severe AKI was noted in 67 (59.8%) patients. At admission, the mean serum cystatin C was 1.85 (0.57) mg/dL. Median (interquartile range) RAI score was 4 (4, 8). RAI =8 was observed in 70 (62.5%) patients, of which 51 developed severe AKI; relative risk 1.9 (95% confidence interval [CI]: 1.3, 2.9); P = 0.002. AUC (standard error) for predicting severe AKI was better for serum cystatin C, 0.9 (0.03), compared to that for RAI, 0.75 (0.05); P = 0.01. For serum cystatin C among children with RAI =8, the AUC was 0.83 (0.04), P = 0.211, compared to RAI alone. Serum cystatin C value of 1.6 mg/dL had 91% sensitivity and 77.3% specificity for predicting severe AKI; relative risk 5.6 (95% CI: 2.7, 11.9); P < 0.001.
Conclusion: Serum cystatin C at PICU admission in itself is a better tool than RAI alone, to predict severe AKI within 72 hr. Serum cystatin C does not significantly improve the discriminative capability of RAI for severe AKI within 72 hr of PICU admission.
| S16 Impact of using reference change value of serum creatinine in the diagnosis, staging, and outcome of acute kidney injury in critically ill children: An exploratory study|| |
S. Shiri1, S. Joseph2, A. V. Lalitha3, A. Devanath4, T. Thomas2, A. Vasudevan1
Departments of 1Pediatric Nephrology, 2Biostatistics, 3Pediatric Intensive Care and 4Clinical Biochemistry, St John's Medical College and Hospital, Bengaluru, Karnataka, India
Introduction: The diagnosis and staging of AKI by the KDIGO creatinine criteria are based on small increase of serum creatinine (sCr) from baseline and are significantly associated with morbidity and mortality. However, the criteria can be a challenge in the interpretation as sCr is subjected to intrinsic variability, which may affect the reliability of diagnosis and staging of AKI. Hence, it is pertinent to include intrinsic or intra-individual biological variation (CVi) of sCr while evaluating sCr to appreciate the significant change in a child diagnosed with AKI using the KDIGO criteria. Reference change value (RCV) is defined as value that exceeds the critical difference between two sequential results to be deemed as significant (or true) change which incorporates the total variation associated with both the results.
Methods: The objectives were to estimate and derive the RCV of sCr in the Indian children and validate and compare the burden and severity of AKI in critically ill children, according to the pediatric RCV optimized for AKI in children (pROCK) and t KDIGO creatinine criteria, and their association with morbidity and in-hospital mortality. A total of 199 children aged <1–10 years without any risk factor for AKI were analyzed for sCr, and a second sample measured within a duration of 30 days was selected to derive the 95th percentile RCV based on the age and initial creatinine. AKI according to the pROCK was defined as an increase in the sCr after adjusting for RCV. pROCK was applied in a cohort of 175 critically ill children (age <10 years) recruited from an ongoing observational study in a pediatric intensive care unit (PICU). We compared the burden of AKI in 175 hospitalized children according to the pROCK and KDIGO creatinine criteria and their association with duration of ventilation and inotropes, length of stay in PICU and hospital, and risk of mortality in hospital.
Results: Median age was 2.8 years (0.3–10 years). The most common diagnosis was sepsis with septic shock (60%). The mean PRISM III score was 15 (range 8–26). 65% required ventilation (50% invasively ventilated). The burden of AKI by the KDIGO staging was 39.4% (n = 69) with the requirement of renal replacement therapy (RRT) in 20.4%. The most common indication for RRT was oligoanuria (88%) followed by refractory metabolic acidosis (82%). On reclassification of AKI staging by using pROCK, the burden of AKI reduced by 17% (n = 39) (39.4% in the KDIGO group vs. 22.2% in the pROCK). AKI stage I, II, and III by KDIGO criteria changed from 42%, 33.3%, and 24.6% to 32%, 7.2%, and 17.3%, respectively, when reclassified using the pROCK. Majority (83%) with stage I and 26% with stage II AKI by the KDIGO staging were reclassified as not having AKI using pROCK, while 74% with stage II AKI were reclassified as stage I AKI [Table 1]. There was no difference in the patient outcome between KDIGO-based and pROCK-based staging of AKI, with duration of ventilation, inotropes, and ICU and hospital stay being significantly higher in those with AKI compared to those without AKI in both groups. Children with AKI in the KDIGO as well as pROCK group had higher mortality compared to those without AKI (odds ratio = 4.32; 95% confidence interval [CI] 1.88–9.94 and 3.32; 95% CI 1.46–7.7, respectively).
|Table 1: Change in staging of acute kidney injury by pROCK compared to Kidney Disease Improving Global Outcomes (KDIGO) criteria|
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Conclusion: In critically ill children, the diagnosis and severity of AKI based on RCV adjusted sCr are lower when compared to the KDIGO criteria. However, there was no impact on morbidity or mortality.
| S17 A study of the renal angina index as a clinical tool to predict acute kidney injury in patients admitted to pediatric intensive care unit|| |
M. K. Gupta, S. Saxena, M. Bhargava, A. Mehta
Department of Pediatrics, Sawai Man Singh Medical College, Jaipur, Rajasthan, India
Introduction: Acute kidney injury (AKI) is one of the risk factors associated with high risk of morbidity and mortality in critically ill pediatric patients. Reliable prediction of AKI may optimize treatment. Therapy for AKI is likely limited by the inability to reliably diagnose AKI in its early stages. Combination of AKI risk score and injury level score, together termed as renal angina index (RAI), is used to predict subsequent development of AKI in the pediatric intensive care unit (PICU)-admitted patients on day 3 of PICU admission. Few studies have investigated the application of RAI to detect AKI in critically ill pediatric patients. This study aimed to predict subsequent AKI in children admitted to the PICU using RAI. We intended to determine the proportion of children in a PICU with a positive RAI on day 0, who develop AKI on day 3, and to compare the predictive ability of the RAI with individual markers of renal injury, for the development of AKI.
Methods: This was a prospective observational study including 280 children aged between 1 month and 18 years with no previous or existing kidney disease, admitted to the PICU over 1 year. RAI was assessed on day 0 (from 8 to 12 hr of PICU admission). RAI was calculated from the product of the renal risk and renal injury score. Renal angina positivity was defined as RAI >8. On day 3, serum creatinine was estimated and estimated glomerular filtration rate was calculated. RAI was correlated with the presence/absence of AKI on day 3. RAI positivity was also correlated with duration of PICU stay, need of dialysis, need of inotropic support, duration of mechanical ventilation, and mortality.
Results: Of 280 patients, RAI positivity on day 0 (8–12 hr of hospital admission) was seen in 58 patients (20.7%). Of 58 RAI-positive patients, 38 patients (65.5%) developed AKI on day 3 compared to 19 patients of 222 (8.6%) in the RAI-negative group (P < 0.001). The mean duration of mechanical ventilation was 72.0 ± 83.5 hr and 9.1 ± 25.6 hr in the RAI-positive and -negative groups, respectively (P < 0.001). The mean duration of hospital stay in the RAI-positive group was 6.95 ± 4.33 days compared to 4.11 ± 1.64 days in the RAI-negative group. Mortality was significantly higher in the RAI-positive group (22.4%) compared to RAI-negative group (8.6%).
Conclusions: RAI is a simple and effective clinical tool to determine AKI in critically ill pediatric patients. It could be of great importance in the future, especially in developing countries where costly biomarkers or diagnostic tools for the detection of AKI are scarce or not available.
| S18 Change in clinical and biochemical parameters after using 0.9% normal saline as maintenance intravenous fluid in noncritically ill hospitalized children|| |
D. Malviya1, S. Sharma, A. Rani2, K. Kapoor1, N. Srivastava3, R. Gera1
Departments of 1Pediatrics, 2Biochemistry and 3Community Medicine, Vardhaman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
Background: The recent recommendations are to use isotonic fluids as maintenance intravenous fluids (mIVFs) in children and the most commonly prescribed fluid is 0.9% normal saline (NS), but there are concerns of hypernatremia, fluid overload, and hyperchloremic metabolic acidosis, adversely affecting kidneys and leading to increased morbidity and even mortality. Most of the available literature is in the adult population. There is still not enough evidence to approve or disapprove 0.9% NS as safe mIVF in children. This study was done to assess the clinical and biochemical effects of 0.9% sodium chloride used as isotonic mIVF in general pediatric noncritically ill patients.
Methods: This was a descriptive cohort study from September 2018 to March 2020 on admitted children from 2 months to 12 years requiring mIVF for minimum 24 hr. Change in blood pressure(BP) and biochemical parameters such as serum sodium, chloride, and bicarbonate were studied at 24 and 48 hr.
Results: Of 1920 children requiring admission, 250 children were analyzed. Mean age was 3.79 ± 3.2 years with majority (43.6%) in the age group of 2 months to 1 year. Majority of patients admitted had pulmonary infection followed by seizures and central nervous system infections. There was no significant change in blood pressure at any time point. Mean serum chloride levels at baseline, 24 hr, and 48 hr were 103.8 ± 4.7, 104.5 ± 4.6, and 105.3 ± 4.5 mEq/L, respectively, with a significant rise at 48 h of mIVF (P < 0.001) and among three points of time (P < 0.01). Mean serum bicarbonate levels were 23.5 ± 1.2, 23.2 ± 1.2, and 23.1 ± 1.2 mEq/L at baseline, 24 hr, and 48 hr, respectively, with significant decrease at 24 hr and 48 hr from baseline (P = 0.02; P < 0.001). There was statistically significant rise in children with metabolic acidosis (pH <7.31 with serum bicarbonate level <22 mEq/L), i.e., 0%, 1.6% (4), and 3.6% (9) at baseline, 24 hr, and 48 hr, respectively (P < 0.01). There was no significant incidence of hyponatremia or hypernatremia.
Conclusion: Normal saline as mIVF in noncritically ill pediatric patients does not cause any significant change in serum sodium level or blood pressure but leads to significant increase in serum chloride levels, leading to hyperchloremia and metabolic acidosis, which may adversely affect kidneys and renal outcome. As a large number of children require mIVF, magnitude of this effect can be considerable.
| S19 Urinary beta-2 microglobulin levels in children with nephrotic syndrome: A comparison between steroid-sensitive and steroid-resistant nephrotic syndrome|| |
D. Yadav1, M. Mantan1, U. Jhamb1, B. Mahajan2
1Department of Pediatrics, Maulana Azad Medical College and Lok Nayak Hospital, 2Department of Biochemistry, GIPMER, Delhi, India
Introduction: Children with steroid-resistant nephrotic syndrome (SRNS) are usually treated with drugs such as calcineurin inhibitors (CNIs), cyclosporine, and tacrolimus. These drugs cause nephrotoxicity on long-term use, and a renal biopsy is required to identify the tubulointerstitial damage. While the utility of beta-2 microglobulin (B2M) has been seen in chronic kidney disease (CKD) and renal transplantation, it has not been adequately studied in nephrotic syndrome. The primary objectives of the study were to estimate the urinary B2M levels in children with nephrotic syndrome; the study of association with disease type, duration, CNI use, and renal biopsy findings was the secondary objective.
Methods: This cross-sectional study was done at a tertiary care teaching hospital between April 2019 and March 2020; 60 children (2–18 years) with steroid-sensitive nephrotic syndrome (SSNS) and SRNS (30 in each group) in remission were enrolled. SRNS patients were included after at least 1 year of treatment with CNI and were currently in complete or partial remission. Children with congenital nephrotic syndrome, active urinary tract infection, acute kidney injury, or CKD were excluded. Baseline biochemical investigations were done for all; a 24-hr urine collection for the estimation of protein, creatinine, and sodium was done; spot samples for urinary B2M were collected after alkalinizing the urine and stored at -80°C till further testing. Urine B2M level estimation was done by an ELISA (Calbiotech # BM010T)-based kit.
Results: The median (interquartile range) age at enrolment for SSNS and SRNS patients was 7 (4.1, 9) and 11 (8.3, 12) years and of disease duration was 3 (1.5, 4.8) and 5.5 (4, 6.9) years, respectively. The median estimated glomerular filtration rate of SSNS and SRNS was 125.1 (110.3, 148.6) and 111.9 (101.8, 143.9) ml/min/1.73 m2; all other biochemical parameters were comparable in both groups. Urinary B2M levels were significantly higher in SRNS as compared to SSNS group in remission (2.6 μg/ml vs. 0.75 μg/ml; P < 0.0001). Urinary B2M levels were positively correlated with proteinuria (r = 0.57; P = 0.0008), serum creatinine (r = 0.5; P = 0.002), and serum cholesterol (r = 0.6; P = 0.006), while no correlation was found in the SSNS group. Patients who received cyclosporine for more than 2 years had higher median urinary B2M levels as compared to those who received the drug for less than 2 years (2.63 vs. 1.83 μg/ml; P = 0.03). The median urinary B2M values were higher in children who received tacrolimus (3.5 μg/ml) even for those who received the drug for <2 years. Median B2M values levels were higher inpatients with focal segmental glomerulosclerosis (FSGS) than in minimal change disease (MCD) (3.5 μg/ml vs. 2.5 μg/ml), though this difference was not statistically significant.
Conclusions: Urinary B2M levels were higher in SRNS patients compared to SSNS disease in remission and those with FSGS biopsy findings compared to MCD. The B2M levels correlated well with CNI use of >2 years and were elevated earlier in patients receiving tacrolimus compared to cyclosporine. Urinary B2M levels appear to be a promising noninvasive tool to identify early tubular damage and progression in patients with SRNS disease on therapy with CNIs.
| S20 Alarming rates of psychological problems among caregivers of pediatric kidney patients admitted during the COVID-19 pandemic lockdown|| |
R. Sharma1, R. Pilania1, L. Dawman1, K. Kumar2, N. Kaur1, R. Sharma1, K. Tiewsoh1
Departments of 1Pediatrics and 2Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
Introduction: Caregivers of children with comorbidities suffer from various psychological problems. We envisage more such complications during this COVID-19 pandemic.
Methodology: A cross-sectional study to assess psychological issues in caregivers of children with kidney diseases, admitted during the lockdown period in India, was done. Psychological tools including Peritraumatic Distress Inventory, Insomnia Severity Index, Depression Anxiety Stress Scale II (DASS II), Positive and Negative Affect Schedule (PANAS), and a new “COVID Stress Survey Questionnaire” were used. Standard statistical analysis was done.
Results: Forty-seven caregivers (33 mothers, 14 fathers) were included. Of these, 33 (70.2%) experienced psychological distress. On PANAS, 45 (95.7%) scored below cutoff on positive effect and 42 (89.4%) scored above cutoff on negative effect. The DASS II score revealed that 38 (80.9%) reported mild stress, 23 (48.9%) had severe anxiety, and 37 (78.7%) had moderate depression. Upper middle socioeconomic status caregivers reported more insomnia. Further, parents of children with acute kidney injury (AKI) or prolonged hospital stay scored higher on subjective distress and aversive feelings.
Conclusion: We observed an alarming level of distress, insomnia, and anxiety among caregivers, more so in upper middle socioeconomic status, and among children with AKI and prolonged hospital stay. We suggest that due counseling should be done.
| S21 A cross-sectional comparative study of children <30 months old having chronic kidney disease stage =3 versus healthy children in terms of neurocognitive outcome|| |
S. Vikas, L. Saini, R. Sharma, L. Dawman, G. Singh, K. Tiewsoh
Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
Introduction: The effect of uremic milieu and other disease-related variables of chronic kidney disease (CKD) on neurocognitive development is not well understood. As brain development occurs in the first 2 years of life, we desired to study the effect of CKD on neurocognitive outcome in children during this period.
Methods: We performed a comparative cross-sectional study on 52 children <30 months old with CKD stage =3 and an equal number of age-matched healthy children visiting immunization clinics. Clinical details and examination were recorded. Developmental Assessment Scales for Indian Infants (DASII) was administered under controlled environment to case and age-matched healthy children by trained personnel, and the results were validated by a pediatric neurologist. Relevant investigations done for cases were documented. Neurocognitive outcome was noted under 3 domains: motor quotient (MoQ), mental quotient (MeQ), and development quotient (DQ). Appropriate statistical tests were performed.
Results: The mean MoQ in CKD children was 66.52 ± 19.06 compared to 89.67 ± 8.62 in healthy group; the mean MeQ was 78.10 ± 13.86 in cases compared to 92.56 ± 7.44 in control group; and the mean DQ in cases was 72.63 ± 15.15 and in healthy controls was 91.03 ± 7.74 with P = 0.001. Of the total cases, 44% (n = 23) were stage 3, 44% (n = 23) stage 4, and 11% (n = 6) stage 5. We observed that mean MoQ in stage 3 was 72.61 ± 18.63, decreased to 63.48 ± 17.08 in Stage 4 and 54.83 ± 22.77 in Stage 5. Similarly, MeQ was 83.65 ± 13.56 in stage 3, lowered to 75.65 ± 11.44 in stage 4 and 66.7 ± 15.33 in stage 5. Further, DQ was 79.00 ± 13.54 in stage 3, dipping to 69.48 ± 13.30 in stage 4 and 60.33 ± 18.54 in stage 5. On further analysis, only weight, height, occipitofrontal circumference, pH, and eGFR had some correlation with neurocognitive score.
Conclusion: Our study found that children <30 months old, with CKD stage =3, had poor neurocognitive outcome in terms of MoQ, MeQ, and DQ. The effect increases with progression of disease. Besides, anthropometry and acidosis seem to have an impact on outcome. Management targeting growth, acidosis, and slowing progression of CKD may be necessary to have a good neurocognitive outcome.
| S22 Protection for measles, mumps, and rubella in children and adolescents with chronic kidney disease|| |
A. Meyyan1, A. Dabas1, M. Mantan1, V. Manchanda2
Department of 1Pediatrics and 2Microbiology, Maulana Azad Medical College and Lok Nayak Hospital, Delhi, India
Introduction: Children with chronic kidney disease (CKD) and those with renal transplants are at increased risk for vaccine-preventable infections. Lower seroconversion rates following vaccination have been reported in children with CKD, with limited data about the seropositivity against measles, mumps, and rubella (MMR) among them. The primary objectives of the study were to estimate the IgG antibody titers against measles, mumps, and rubella in children and adolescents with CKD (2–18 years) who had received at least one dose of measles/MMR vaccine. The association of antibody titers with age, duration, stages, and causes of CKD was also studied.
Methods: This case–control study from a tertiary care teaching hospital from January 2019 to January 2020 enrolled 120 children (60 cases and 60 healthy controls), aged between 2 and 18 years. Patients on dialysis and posttransplant were excluded from the study. History, physical examination, and details of immunization were recorded. Antibody titers were estimated by using ELISA-based kits provided by IBL International (for measles), Immunolab (for mumps), and Radim (for rubella), Germany, as per the manufacturer's instruction. Seroprotection was defined as antibody titers ≥12 IU/ml for measles, ≥30 IU/ml for mumps, and ≥10 IU/ml for rubella.
Results: The median (interquartile range [IQR]) age at enrolment was 99 (64.3, 141.3) months. All CKD patients had received two doses of measles containing vaccine, and only 70% of the control group had received two doses of vaccine. The seroprotection rates for MMR were 90%, 71.7%, and 86.7% in the CKD group and 86.7%, 77.7%, and 88.3% in the control group, respectively. The median (IQR) antibody titers in children with CKD were 60.21 (24.58, 145.01) IU/mL, 22.96 (7.16, 84.45) IU/mL, and 256.01 (106.03, 281.37) IU/mL for MMR, respectively. Similarly, antibody levels (IQR) in the control group were 36.65 (12.83, 75.33) IU/mL for measles, 35.50 (14.74, 74.39) IU/mL for mumps, and 154.39 (56.25, 267.91) IU/mL for rubella; P = 0.01 for measles, P = 0.77 for mumps, and P = 0.05 for rubella as compared to cases. Further, the level of seroprotection was lower in CKD stage 4/5 as compared to CKD stage 1–3 for measles (46.59 and 118.45; P = 0.009), mumps (19.0 and 83.0; P = 0.03), and rubella (248.73 and 258.92; P = 0.90 IU/mL), respectively.
Conclusions: Based on the results of our study, we conclude that the seroprotection for MMR was lower in children with CKD though comparable to healthy children. Further, the level of seroprotection was lower in later stages of CKD; therefore, we suggest a booster dose of MMR instead of mums rubella (MR) vaccine to be administered to all children, especially to those in advanced stages of CKD, besides the two doses of a measles containing vaccine. Where facilities for antibody titers are available, a booster can be administered after measuring the levels of antibody titers.
| S23 Incidence and outcomes of acute kidney injury in neonates admitted in neonatal intensive care unit|| |
A. Tiwana, G. S. Dhooria, P. A. Pooni, K. Arora, K. S. Gill
Department of Pediatrics, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
Introduction: Acute kidney injury (AKI) is common in neonates admitted to the neonatal intensive care unit (NICU). AKI is associated with increased morbidity and mortality and a greater long-term risk of chronic kidney disease. Aim was to find the incidence and outcomes of AKI in neonates admitted in the NICU of a tertiary care center.
Methods: This single-center, prospective cohort study included all neonates who received level 3 NICU care during the 1-year period from January to December 2019. Neonates admitted to the NICU and who received intravenous fluids for at least 48 h were included. Neonates who survived less than 48 hr after admission, had lethal chromosomal anomalies, and had severe congenital renal anomalies and urinary tract anomalies or congenital heart disease requiring repair were excluded. AKI was defined according to the modified KDIGO criteria defined as an increase in serum creatinine of >0.3 mg/dL or more (≥26´5 μmol/L) or 50% or more from the previous lowest value. Both AKI and non-AKI neonates were prospectively followed up until discharge. The incidence of AKI was noted and factors affecting AKI were studied. Outcomes studied included mortality and length of NICU stay.
Results: Of 750 neonates screened, 680 neonates met the inclusion criteria; 66 (9.7%) neonates had AKI. The incidence of AKI varied by gestational age group, occurring in 19.1% in neonates born <22–29 weeks, 5% in neonates born at 30–36 weeks, and 15.6% in neonates born at ≥37 weeks. Mean birth weight of enrolled neonates was 2142.9 ± 735 g and mean gestational age was 34.4 ± 3.4 weeks. Out of 66 AKI cases, 66.7% had stage 1, 18.2% had stage 2, and 15.2% had stage 3 AKI as per the modified KDIGO criteria. Median day of onset of AKI was 4 (interquartile range 3–6). Early-onset AKI (onset <7 days) was seen in 84.8% of neonates and 15.1% of neonates had late-onset AKI (onset ≥7 days). Number of cases with adverse outcome was 87 (12.8%; deaths 2.3%). Of 87 babies with adverse outcome, 37.8% had AKI compared to 10.1% without AKI (P < 0.001). Neonates with AKI had longer hospital stay (mean 16 ± 16.5 vs. 10.2 ± 9.3 days). AKI resolved in 70.8% of neonates till the time of discharge.
Conclusion: The incidence of AKI in neonates was found to be 9.7%. In the study, neonates with AKI had a significantly more adverse outcome and a longer duration of hospital stay compared to neonates without AKI.
| S24 Serum levels of immunoglobulin E and interleukin-13 in nephrotic syndrome|| |
Department of Pediatrics, KMC Attavar, Mangalore, Karnataka, India
Introduction: Studies on nephrotic syndrome (NS) suggest that T-cell dysfunction and an impaired cytokine network may alter the glomerular permeability and glomerular filtration barrier, contributing to proteinuria. Limited literature is available among children with NS, on the estimation of immunoglobulin E (IgE) and interleukin-13 (IL-13) levels. The objectives were to estimate the serum IgE and IL-13 levels in children with NS and to correlate their levels between active phase and remission (defined as urine protein nil for 3 consecutive days).
Methods: Following ethical clearance and informed consent, 40 children with active NS admitted were included. Patient data such as relevant history, complete physical examination, with systemic findings, and relevant laboratory investigations were documented. Serum IgE and IL-13 levels were estimated and repeated after the patient was in remission stage.
Results: Forty children, with a mean age of 8.1 ± 3.6 years, diagnosed with NS were studied. The biochemical parameters were not significantly different between subgroups with first episode, infrequently relapsing NS, and frequently relapsing NS. The incidence of hypertension was 57.5%. Number of days to remission was 8–14 days. Serum IgE and IL-13 levels were significantly elevated among all the study population. In remission, serum IgE and IL-13 values reduced or normalized. 50% of the study population persisted to have elevated IgE levels despite remission. Significant correlation was noted between the rise and fall in the levels of serum IL-13 and serum IgE.
Conclusion: IgE and IL-13 were elevated in the active phase of the disease and significantly reduced during remission. While levels of biochemical markers rose from the first episode of NS to infrequent relapsing NS and frequently relapsing NS, this could not attributed statistical significance. Persistent higher levels of IgE were noted among 50% of cases, indicating abnormal immune state of the patient. The rise and fall in the levels of serum IgE were noted to have a significant correlation to the rise and fall in levels of IL-13. The above findings indicated the role of serum IgE and IL-13 in pathogenesis of the NS.
| S25 Spectrum of major infections in children admitted with nephrotic syndrome: Finding the focus|| |
G. Nair, M. V. Patil
Department of Pediatrics, Jawaharlal Nehru Medical College, KAHER, Belagavi, Karnataka, India
Introduction: Infections in nephrotic syndrome are challenging. Infections trigger the onset of disease or relapse, and hence, identification and prompt treatment are first-line concerns in hospitalized children who are susceptible to a wide spectrum of organisms. In our study, we aimed at determining the type of infection, causative organism, and risk factors causing infections in admitted cases of nephrotic syndrome over a period of 6 months.
Methods: A cross-sectional study was conducted in our tertiary care center in children aged between 1 and 18 years with nephrotic syndrome from January 2020 to August 2020. Major infections were defined as infections affecting deep organs and tissues which warrant hospitalization. Suspicion of focus of infection and appropriate diagnostic methods were employed to confirm the diagnosis, and an empirical antibiotic therapy based on the antibiogram was started. Complete hemogram, blood culture, and hs-CRP values were mandatorily evaluated for all patients, and based on the focus of infection, relevant investigations such as ascitic fluid analysis, urine analysis, and pus culture were done. Demographic data, anthropometry examination, and clinical examination were recorded in predesigned pro forma by bedside clinical history and examination. Collected data were analyzed using R software (R Core team, R Foundation for Statistical Computing, Vienna, Austria; version 4.0.2, released 2017).
Results: A total of 40 children were admitted with nephrotic syndrome during this pandemic period of whom 15 (40%) developed episodes of major infections; 14 out of 15 during relapse. Peritonitis was the most common infection (5), followed by urinary tract infection and septicemia. Acute gastroenteritis, cellulitis, and pneumonia were other infections observed. Klebsiella pneumonia and Streptococcus pneumonia, which have been rarely reported in association with pediatric nephrotic syndrome, were also isolated. Appropriate antibiotic-sensitive regimen was followed based on the antibiogram with minimum inhibitory concentration provided by the microbiology laboratory. All patients responded to treatment well, except for one death owing to severe renal failure, morbid obesity, and candidal sepsis.
Conclusion: Infections can be serious and life-threatening in nephrotic syndrome. Targeted and specific antibiotic coverage should be introduced as soon as possible for improving outcome. In concordance with literature, we found hypoalbuminemia as a risk factor, in our study; hs-CRP level was found to be a reliable inflammatory marker. The fewer deaths in our study in contrast to previous Indian studies can be attributed to the early presentation, high index of suspicion, and prompt institution of treatment.
| S26 Varying zinc levels during nephrotic syndrome: An observational study|| |
Department of Pediatrics, MLN Medical College, Prayagraj, Allahabad, Uttar Pradesh, India
Introduction: Nephrotic state is associated with loss of many important micronutrients. We aimed to study levels of zinc during initial episode/relapse and remission of idiopathic nephrotic syndrome. Zinc has been recognized to have a pivotal role in immune regulation and low zinc level may lead to relative type 2 cytokine bias, which increases risk of infection known to precipitate a relapse.
Methods: A prospective observational study was conducted in a tertiary care center of North India over 12 months. Patients aged 1–14 years having steroid-sensitive nephrotic syndrome were included. Those with clinical evidence of malnutrition, with systemic diseases, or taking zinc or zinc containing supplements 3 months before the study period were excluded. Blood and urine samples were obtained in the morning following an overnight fasting, at relapse/initial episode, and at remission. Serum zinc level was done at confirmed initial episode/relapse and then at the time of remission. Data were summarized as mean ± standard deviation. Groups were compared by paired t-test.
Results: Fifty-five patients were recruited; three patients showed steroid resistance and were excluded. Three patients did not complete the study; data of 49 patients were analyzed. Of 49 patients, 19 were analyzed at the initial episode, 20 were infrequent relapsers, and 10 were frequent relapsers. The latter two groups were analyzed at an episode of relapse. Serum zinc levels at enrolment for patients with initial episodes were 49.31 ± 33.24 μg/dl (subnormal) and at remission was 104 ± 47.61 μg/dl (normal; P = 0.0002). Serum zinc levels in infrequent relapsers at relapse were 46.75 ± 27.58 μg/dl (subnormal) and at remission was 144.9 ± 74.94 μg/dl (normal; P < 0.00001). Serum zinc levels in frequent relapsers at relapse were 44.3 ± 17.82 μg/dl (subnormal) and at remission was 104.3 ± 29.49 μg/dl (normal; P < 0.00001). Overall, there was a statistically significant difference in the mean value of serum zinc during relapse and remission (P < 0.05).
Conclusion: This study shows that serum zinc level is lower than normal range during relapse/initial episode and it normalizes with the remission of proteinuria. The clinical implications of these findings can pave the way for further studies.
| S27 Etiology and clinical profile of acute glomerulonephritis in children attending a tertiary care hospital in west bengal|| |
O. Roy, S. Routh, D. Raychaudhuri, M. Nandy
Department of Pediatrics, Medical College and Hospital, Kolkata, West Bengal, India
Introduction: Acute glomerulonephritis (GN) consists of those glomerular diseases that present with an acute nephritic syndrome which is characterized by sudden onset of hematuria, edema, hypertension, and diminished urine output caused by immunologically mediated injury to the glomerulus. The injury may be preceded by an infection (poststreptococcal, staphylococcal, or relatively uncommon infections such as Salmonella and hepatitis B virus) or might be due to noninfectious causes such as lupus nephritis. The aim of the study was to determine the etiology and clinical profile of patients with acute glomerulonephritis and compare postinfectious GN (PIGN) and non-PIGN (NPIGN).
Methods: In 57 patients admitted over a period of 1 year, who fulfilled the inclusion and exclusion criteria of acute GN, relevant data (history, clinical findings, and laboratory investigations) were collected on a predesigned case pro forma and tabulated.
Results: The female:male ratio was 1.28:1; mean age at presentation was 6.8 years. Clinical profile comprised edema 100%, hypertension 92.9%, diminished urine output 68.4%, gross hematuria 63.2%, and heart failure 24.6%. Acute PIGN was preceded by sore throat in 75% and streptococcal pyoderma/impetigo in 17.8% cases. Investigations showed anemia 78.9%, dyselectrolytemia 28.1%, urine RBC casts 43.9%, and nephrotic range proteinuria 22.8%. Renal biopsy in 33.3% showed crescentic GN 12.2% followed by lupus nephritis class 4 10.5%. Acute kidney injury (AKI) occurred in 45.6%; renal replacement therapy (RRT) was required in 19.3%. There were 8.8% deaths. Etiology consisted of poststreptococcal glomerulonephritis 49.1% and infections with Staphylococcus 3.5%, enteric fever 1.8%, hepatitis B 1.8%, and scrub typhus 5.4%. Etiology for NPIGN was lupus nephritis 19.2%, IgA vasculitis 5.3%, and c-ANCA–positive crescentic GN 3.5%. A comparative account of PIGN and NPIGN showed a higher possibility of encephalopathy, severe anemia, poorer eGFR at peak of illness, AKI, requirement of RRT, and death in the NPIGN group (P < 0.05)
Conclusion: Female preponderance, high incidence of anemia, higher occurrence of AKI, cases of PIGN following unusual infections (such as enteric fever and scrub typhus), and predominance of lupus nephritis in NPIGN were unique. Comparison of PIGN and NPIGN showed a significant difference in the incidence of AKI and need for RRT with subsequently poorer outcome in the NPIGN group.
| S28 Cardiac abnormalities in children with chronic kidney disease in resource-limited settings|| |
N. Bhagat1, L. Dawman1, J. Meena1, S. Naganur2, K. Tiewsoh1, B. Kumar2, K. L. Gupta3
Department of 1Pediatrics, 2Cardiology and 3Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
Introduction: Cardiac abnormalities such as left ventricular (LV) hypertrophy (LVH),and systolic and diastolic dysfunction develop and progress as the kidney function further declines in children with chronic kidney disease (CKD). Multiple risk factors have been implicated that may contribute to cardiovascular abnormalities. Echocardiographic evaluation of LV function by measuring regional myocardial relaxation and contraction velocities provides a sensitive and repeatable means of assessing both diastolic and systolic function of myocardium. However, the data relating to this technique used in childhood CKD are sparse. Published data suggest that diastolic dysfunction is present in children on chronic dialysis. Literature on cardiac changes in predialysis children with CKD is limited. The study was aimed to find the prevalence of cardiac changes in children <16 years with CKD and their association with various parameters.
Methods: We assessed the systolic and diastolic function using two-dimensional echocardiography and M-mode measurements of LV indexed for body surface area and z-scores were calculated. Results were compared with age, sex, stage of CKD, anemia, estimated glomerular filtration rate (eGFR), and various metabolic parameters.
Results: LV diastolic dysfunction was seen in 88%, followed by increased LV dimensions in 33.6%, LV systolic dysfunction in 16%, and right ventricle (RV) systolic dysfunction in 11.2% while increased pulmonary artery systolic pressure was seen in 9.3% of cases. LV dimensions correlated directly with parathormone levels and inversely with eGFR, serum calcium and hemoglobin levels. LVH correlated directly with parathormone while inversely with eGFR, serum calcium, and hemoglobin. Ejection fraction directly correlated to eGFR and serum calcium while inversely related to parathormone. The ratio of e to a wave on yissue Doppler imaging e/a inversely correlated with serum creatinine and parathormone. Left pulmonary artery pressure directly correlated with age and inversely with eGFR. RV systolic function assessed by tricuspid annular plane systolic excursion correlated inversely with hemoglobin.
Conclusion: LV diastolic dysfunction and increased LV dimensions were the most common cardiac abnormality in children with CKD. LV dimensions correlated directly with parathormone levels and inversely with eGFR, serum calcium, and hemoglobin. Diastolic dysfunction positively correlated with serum creatinine and parathormone levels.
| S29 Serum tumor necrosis factor-alpha as a marker of disease activity in children with nephrotic syndrome|| |
B. C. Gowtham, L. Dawman, A. Rawat, K. Tiewsoh
Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
Introduction: Nephrotic syndrome is a common renal disorder in children. There is evidence of immune dysfunction with a possible circulatory factor, i.e., proinflammatory cytokine, hypothesized as the mediator of inflammation. Studies have shown that tumor necrosis factor alpha (TNFa), as a proinflammatory cytokine, might provoke the expression of other proinflammatory cytokines and is believed to have a significant relationship in the pathogenesis of nephrotic syndrome. This study aimed to evaluate serum TNFa as a marker of disease activity in children with idiopathic nephrotic syndrome and compare it with healthy controls.
Methods: This prospective study was conducted in nephrotic syndrome children and healthy controls aged up to 14 years between July 2018 and December 2019. Serum TNFa levels were measured at presentation and at remission or after a minimum of 60 days of steroid therapy if remission was not achieved.
Results: Seventy children with nephrotic syndrome were compared with 11 healthy controls. Sixty-seven patients had steroid-sensitive nephrotic syndrome and 3 had steroid-resistant nephrotic syndrome (SRNS). The median (interquartile range [IQR]) of TNFa levels at presentation in the cases and controls was 10.48 (8.03, 15.51) pg/mL versus 8.39 (7.2, 11.18) pg/mL (P = 0.17). The median (IQR) of TNFa levels in the cases at presentation and at remission was 10.48 (8.03, 15.51) pg/mL versus 4.73 (0.67, 9.51) pg/mL (P < 0.001). The median (IQR) of TNFa levels in SRNS at presentation and after treatment was 7.68 (6.6, 8.08) pg/mL versus 10.55 (9.03, 12.22) pg/mL (P = 0.50). The median (IQR) of the change in the TNFa levels among the cases achieving remission within 60 days of steroid therapy was found to be 4.73 (0.67, 9.51) pg/mL and among the cases failing to achieve remission was found to be -5.05 (-5.62, -2.03) (P = 0.028). The negative median value in the SRNS patients indicates that there was a rise in the TNFa levels despite the steroid therapy for 60 days.
Conclusions: Serum TNFa levels decrease with corticosteroid therapy in children with steroid-sensitive nephrotic syndrome, which correlates clinically with the achievement of remission. In SRNS, there was persistent elevation of serum TNFa levels.
| S30 A prospective epidemiological study of acute kidney injury in a tertiary care center|| |
M. Chakravarthi, S. Agarkhedkar, M. Matnani
Department of Pediatrics, Dr. D. Y. Patil Medical College, Pune, Maharashtra, India
Introduction: Acute kidney injury (AKI) is a potentially reversible event that requires quick identification, timely management, and meticulous follow-up. The diagnosis of AKI in the pediatric intensive care unit (PICU), though prompt, may have deleterious outcomes, if interventions are delayed. We intended to study the incidence of AKI and assess the etiology of AKI, in a tertiary care center.
Methods: The study was performed over 12 months from November 2019 to October 2020 at the PICU of a single center and AKI was staged as per the KDIGO classification. Data about the patient, causes, management and the need for renal replacement therapy (RRT) were collected prospectively. Patients were classified as prerenal, renal and postrenal according to etiology.
Results: The incidence of AKI in our study was 13%; 71 children (48 boys, 23 girls) were included and boys were affected twice more than girls. Etiology was prerenal (19), renal (49) and postrenal (3 posterior urethral valves). The renal causes of AKI were acute tubular necrosis - 24 (related to sepsis, infections, congenital heart disease, and postsurgical); glomerular - 10 (hemolytic uremic syndrome, rapidly progressive glomerulonephritis, and infection-related glomerulonephritis), and nephrotoxic drug injury - 15. Deaths included 19 in stage 2 AKI (12 congenital heart disease with sepsis, 3 encephalitis, 2 fulminant hepatitis, and 2 severe dengue fever) and 7 in stage 3 AKI [3 metabolic renal and liver disease, 1 each of sepsis, malignancy, fulminant hepatitis, fulminant cytomegalovirus infection; [Table 1]]. 19 patients required RRT; 15 peritoneal dialysis and 4 hemodialysis. 15 out of 24 (62.5%) had nephrotoxic drug toxicity. The mean follow-up period was 6 months (ranging from 1 to 12 months) with 2 (8.3%) out of 24 progressing to end-stage renal disease.
|Table 1: Relative prevalence of acute kidney injury stages and mortality|
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Conclusions: Our study showed a high mortality in stage 2 AKI wherein all the patients had an underlying pre-existing cardiac, hepatic, or neurological comorbidity along with sepsis. We had a high incidence of nephrotoxicity related to drugs vancomycin and amikacin, which tend to be used as first-line agents in the PICU. Moreover, RRT was not started earlier contributing to the high mortality. This shows that the PICUs need to be sensitized to start RRT early, to decrease the morbidity and mortality.
[Table 1], [Table 2], [Table 3]