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Urinary stones in children are being recognized with increasing frequency. Formerly thought to be the result of dehydration, urinary obstruction, or infection, most urinary calculi in children now are recognized to have an underlying metabolic abnormality. A number of challenges face pediatricians in evaluating and treating children with urinary stone disease. Often the clinical symptomatology is nonspecific and lacks the excruciating renal colic seen in adults. Furthermore, diagnostic clinical laboratory values vary with age and must be differentiated from normal values reported for adult patients. Both environmental and genetic factors are responsible for urinary stones. Many stones have a hereditary basis. Exciting new information is developing about the genetic propensity for urinary stones. Current medical therapies attempt either to reduce the production of a lithogenic solute or to increase urinary solubility. New therapies for prevention and treatment of urinary stone disease are likely to evolve as our understanding of the pathogenesis of these conditions grows.

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OBJECTIVE: The purpose was to determine the value of the standard laboratory and radiologic evaluation of microscopic hematuria in children, and to determine the prevalence of idiopathic hypercalciuria in those children referred for evaluation of unexplained microscopic hematuria. METHODS: This was a retrospective study of 325 children referred from 1985 to 1994 for the evaluation of asymptomatic microscopic hematuria. The diagnostic studies reviewed included serum creatinine, blood urea nitrogen, serum electrolyte studies, serum complement concentration, antinuclear antibody, urinalysis, urine calcium to creatinine ratios, urinary protein to creatinine ratio and/or 24-hour urinary protein excretion, renal ultrasounds, intravenous pyelograms, voiding cystourethrograms, and historical information. RESULTS: All creatinine and electrolyte values were normal for age, and none of the biochemical tests obtained in the children with hypercalciuria was abnormal. Of the 325 patients with idiopathic microscopic hematuria, only 18 had abnormal renal ultrasound examinations and 9 voiding cystourethrograms showed low-grade reflux. Hypercalciuria was found in 29 patients. The family history was positive for urolithiasis in 16% of patients without hypercalciuria compared with 14% of patients with hypercalciuria. A positive family history of hematuria was reported in 25% of patients; 62 patients did not have hypercalciuria and 4 of the patients had hypercalciuria. Microscopic hematuria in children is a benign finding in the vast majority of children. CONCLUSIONS: Our data demonstrate that a renal ultrasound, voiding cystourethrogram, cystoscopy, and renal biopsy are not indicated in the work-up of microscopic hematuria, and microhematuria in the otherwise healthy child is a minimal health threat, rarely indicative of serious illness.

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An 8-year-old boy developed end-stage renal disease 7 years after the in utero diagnosis of bilateral cystic kidneys. There was no history of cystic renal disease in the family. Initial ultrasonographic screening of the parents failed to reveal cysts in the kidneys. Pathological evaluation of the kidney biopsy findings was consistent with the glomerulocystic kidney disease. He had bilateral nephrectomies in preparation for a living related renal transplant at 7 years of age. At that time, a repeated renal ultrasound examination of the mother showed bilateral cystic kidneys. Pathological evaluation of the nephrectomy specimens confirmed the diagnosis of autosomal dominant polycystic kidney disease. In this report, a discussion of the differential diagnosis of glomerular cysts and the relationship of glomerulocystic kidney disease and autosomal dominant polycystic kidney disease is provided.

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

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

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To investigate possible mechanisms of increased urinary calcium excretion and increased prevalence of urolithiasis in 16- to 20-year-old children, oral calcium loading and diuretic tests were performed in 120 normal children in three age groups (7-8, 12-13, and 17-18 years of age). Urinary calcium/creatinine ratios and 24-h urinary calcium excretion were significantly increased following the oral calcium loading test in 17- to 18-year-olds compared with the two younger age groups. Oral furosemide resulted in increased urinary calcium excretion in the 17- to 18-year age group, while hydrochlorothiazide was less effective in reducing urinary calcium excretion in this age group. These results suggest that increased intestinal calcium absorption and decreased renal tubular reabsorption of calcium in 17- to 18-year-olds may be contributing factors in the increased prevalence of nephrolithiasis in older Taiwanese children.

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

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

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Due to the concern that adolescents presenting with nephrotic syndrome are less likely to have minimal change disease than younger children, pediatric nephrologists have tended toward renal biopsy-tailored treatment rather than corticosteroid use in this population. The need for biopsy prior to treatment of nephrotic syndrome in adults has been challenged. A similar challenge to the clinical need for this procedure in adolescents with idiopathic nephrotic syndrome is raised here. The principles of medical decision analysis were applied and calculations were made with the Decision Maker computer program. The life expectancy of an adolescent who receives biopsy-tailored treatment was found to be no different from that of an adolescent who receives empiric corticosteroid treatment. We conclude that renal biopsy is not mandatory for the clinical management of adolescents with idiopathic nephrotic syndrome. Prognostically, a response, or lack thereof, to empiric corticosteroid therapy may be just as informative as a histological diagnosis.

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Hematuria is one of the most common urinary abnormalities found in children. When hypercalciuria was identified as a potential etiology of painless hematuria, many questions arose concerning the general importance of this observation. Subsequently, increased uric acid excretion also has been purported to cause hematuria in children. This review traces the history of these observations and describes the clinical characteristics of the clinical syndrome of hematuria associated with hypercalciuria and hyperuricosuria. Diagnostic criteria of excessive urinary excretion of calcium and uric acid are reviewed; differences in urinary calcium and uric acid excretion between infants and older children are emphasized. Aside from urolithiasis, few long-term consequences from hypercalciuria or hyperuricosuria have been identified, although some debate exists concerning the effect of chronic hypercalciuria upon bone mineralization.

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

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We describe a 6-year-old patient with autosomal dominant polycystic kidney disease, normal renal function, hypertension, and serial echocardiograms showing an aneurysm of the atrial septum. Intracardiac aneurysms have not previously been reported in patients with autosomal dominant polycystic kidney disease.

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