Renal Scarring Research Articles

SARS-CoV-2 pirates the kidneys: A scar(y) story

SARS-CoV-2 can cause diverse severe and lasting damage to the kidneys. In the latest issue of Cell Stem Cell, Jansen et al. utilized data gleaned from human kidney autopsies and human induced pluripotent stem cell-derived kidney organoids to investigate the direct effects of SARS-CoV-2 infection on kidney cells. They found that such infections resulted in renal scarring (notably, tubulointerstitial fibrosis).

Prevalence of reflux nephropathy in Iranian children with solitary kidney: results of a multi-center study

BackgroundGiven the importance of the function of the remnant kidney in children with unilateral renal agenesis and the significance of timely diagnosis and treatment of reflux nephropathy to prevent further damage to the remaining kidney, we aimed to determine the prevalence of reflux nephropathy in this subgroup of pediatric patients.MethodsIn general, 274 children referred to pediatric nephrologists in different parts of Iran were evaluated, of whom 199 had solitary kidney and were included in this cross-sectional study. The reasons for referral included urinary tract infection (UTI), abnormal renal ultrasonography, being symptomatic, and incidental screening. Demographic characteristics, including age and gender were recorded. History of UTI and presence of vesicoureteral reflux (VUR) were evaluated.ResultsOf the 274 children evaluated in this study with the mean age (SD) of 4.71 (4.24) years, 199 (72.6%) had solitary kidney. Among these, 118 (59.3%) were male and 81 (60.7%) were female, 21.1% had a history of UTI, and VUR was present in 23.1%. The most common cause of referral was abnormal renal ultrasonography (40.2%), followed by incidental screening (21.1%), being symptomatic (14.1%), and UTI (5.5%). In 116 children (58.3%), the right kidneys and in 83 (41.7%) the left kidneys were absent. Besides, 14.6% of the participants had consanguineous parents and 3% had a family history of solitary kidney. Upon DMSA scan, the single kidney was scarred in 13.1%, of which only 7.5% were associated with VUR. In addition, proteinuria and hematuria were observed in 6.5% and 1.5% of children, respectively.ConclusionsThe prevalence of reflux nephropathy was 7.5% in children with solitary kidney with a male predominance. Given the relatively high prevalence of reflux nephropathy in these children, screening for VUR in the remnant kidney appears to be essential in this population.

Prediction of Recurrent Urinary Tract Infection in Paediatric Patients by Deep Learning Analysis of 99mTc-DMSA Renal Scan.

Purpose: Tc-99m dimercaptosuccinic acid (99mTc-DMSA) renal scan is an important tool for the assessment of childhood urinary tract infection (UTI), vesicoureteral reflux (VUR), and renal scarring. We evaluated whether a deep learning (DL) analysis of 99mTc-DMSA renal scans could predict the recurrence of UTI better than conventional clinical factors. Methods: the subjects were 180 paediatric patients diagnosed with UTI, who underwent immediate post-therapeutic 99mTc-DMSA renal scans. The primary outcome was the recurrence of UTI during the follow-up period. For the DL analysis, a convolutional neural network (CNN) model was used. Age, sex, the presence of VUR, the presence of cortical defects on the 99mTc-DMSA renal scan, split renal function (SRF), and DL prediction results were used as independent factors for predicting recurrent UTI. The diagnostic accuracy for predicting recurrent UTI was statistically compared between independent factors. Results: The sensitivity, specificity and accuracy for predicting recurrent UTI were 44.4%, 88.9%, and 82.2% by the presence of VUR; 44.4%, 76.5%, and 71.7% by the presence of cortical defect; 74.1%, 80.4%, and 79.4% by SRF (optimal cut-off = 45.93%); and 70.4%, 94.8%, and 91.1% by the DL prediction results. There were no significant differences in sensitivity between all independent factors (p > 0.05, for all). The specificity and accuracy of the DL prediction results were significantly higher than those of the other factors. Conclusion: DL analysis of 99mTc-DMSA renal scans may be useful for predicting recurrent UTI in paediatric patients. It is an efficient supportive tool to predict poor prognosis without visually demonstrable cortical defects in 99mTc-DMSA renal scans.

Urinary neutrophil gelatinase-associated lipocalin might be an associated marker for anticipating scar formation in children with vesicoureteral reflux

Introduction: Vesicoureteral reflux (VUR) is considered as the most common urogenital abnormality occurring in children. There is no reliable and routine clinical test that is non-invasive and rapid for recognizing the renal scars from VUR. Objectives: Urine neutrophil gelatinase-associated lipocalin (uNGAL) can be the best indicator for early diagnosis of scar formation in children with VUR. Patients and Methods: Children with primary VUR admitted to Hamadan’s Besat hospital from March to December 2020 were included in this cross-sectional study. A dimercaptosuccinic acid (DMSA) scan was employed to assess all subjects in order to diagnose scar formation at least 180 days after the last episode of urinary tract infection (UTI). Additionally, uNGAL and its ratio to urine creatinine (uCr) levels were measured. Results: During the study, all 63 cases (male/female, 13.50) with VUR were included for further evaluation. The mean age of the patients was 59.1 ± 34.7 months (range 2 to 132 months). Twelve subjects suffered from unilateral VUR, while bilateral VUR inflicted 51. According to the disease severity, nine patients had mild, 35 had moderate, and 19 had a severe form of VUR. No significant difference was observed between patients with (n = 31) and without (n = 32) renal scars regarding mean levels of the uNGAL and uNGAL/uCR ratios (P>0.05). Conclusion: We found no significant difference between the groups with and without the renal scar in terms of biomarker levels.

Protective Effects of Omega-3 Fatty Acids Supplementation Against Renal Parenchymal Scarring in Children with Acute Pyelonephritis: Results of a Pilot Clinical Trial.

This trial aimed to determine if supplementation with omega-3 fatty acids as an adjunct therapy to antibiotic treatment can have protective effects against renal scar formation after acute pyelonephritis (APN) in pediatric patients. Current evidence points out that besides antibiotic treatment, early administration of antioxidant and anti-inflammatory compounds may be effective in reducing the occurrence of renal damage following APN in children. The main endpoint of the trial was the comparison of the development of renal scarring formation after APN in an omega-3 fatty acids-treated group and in a control-treated group. This prospective randomized, controlled trial study was conducted from March 2016 to May 2018 on 60 children with a diagnosis APN in a tertiary hospital in Iran. After the diagnosis of APN based on the clinical signs and symptoms, urine analysis, urine culture, and dimercaptosuccinic acid renal scan (DMSA scan), the patients were randomly allocated into either the control group (n=30 patients: received standard antibiotic treatment only) or the intervention group (n=30 patients: received standard antibiotic-treatment in combination with oral omega-3 fatty acids based on the children's weight for three consecutive days). A second DMSA scan was performed for the patients at a minimum of six months after treatment. The development of renal scars was evaluated by comparing the baseline DMSA scan lesions with the follow-up DMSA scan lesions. Fifty patients, including 26 and 24 individuals in the control and intervention groups, respectively, completed the entire course of the study. Renal parenchymal involvement based on the baseline DMSA scan was similar in the two groups (p-value =0.85, 0.90, and 0.53 regarding the right, left, and both kidney units together, respectively). Although comparison of the follow-up DMSA scan lesions to the baseline DMSA scan lesions considering the right and left kidneys as separate units between two groups did not reach the significant level, when considering both left and right kidney units together, results showed a statistically significant difference between groups in favor of the intervention group (p-value =0.04). Although preliminary, the results of this study showed that administration of omega-3 fatty acids, a natural supplement with well-known anti-inflammatory and antioxidant properties, as an adjunct therapy to standard antibiotic treatment might significantly reduce the incidence of the occurrence renal scarring following APN in children. Confirmation of these results requires further studies.

Using Machine Learning to Identify Metabolomic Signatures of Pediatric Chronic Kidney Disease Etiology.

Untargeted plasma metabolomic profiling combined with machine learning (ML) may lead to discovery of metabolic profiles that inform our understanding of pediatric CKD causes. We sought to identify metabolomic signatures in pediatric CKD based on diagnosis: FSGS, obstructive uropathy (OU), aplasia/dysplasia/hypoplasia (A/D/H), and reflux nephropathy (RN). Untargeted metabolomic quantification (GC-MS/LC-MS, Metabolon) was performed on plasma from 702 Chronic Kidney Disease in Children study participants (n: FSGS=63, OU=122, A/D/H=109, and RN=86). Lasso regression was used for feature selection, adjusting for clinical covariates. Four methods were then applied to stratify significance: logistic regression, support vector machine, random forest, and extreme gradient boosting. ML training was performed on 80% total cohort subsets and validated on 20% holdout subsets. Important features were selected based on being significant in at least two of the four modeling approaches. We additionally performed pathway enrichment analysis to identify metabolic subpathways associated with CKD cause. ML models were evaluated on holdout subsets with receiver-operator and precision-recall area-under-the-curve, F1 score, and Matthews correlation coefficient. ML models outperformed no-skill prediction. Metabolomic profiles were identified based on cause. FSGS was associated with the sphingomyelin-ceramide axis. FSGS was also associated with individual plasmalogen metabolites and the subpathway. OU was associated with gut microbiome-derived histidine metabolites. ML models identified metabolomic signatures based on CKD cause. Using ML techniques in conjunction with traditional biostatistics, we demonstrated that sphingomyelin-ceramide and plasmalogen dysmetabolism are associated with FSGS and that gut microbiome-derived histidine metabolites are associated with OU.

Risk factors for renal scarring and clinical morbidity in children with high-grade and low-grade primary vesicoureteral reflux

Primary vesicoureteral reflux (VUR) is associated with urinary tract infections (UTIs) and renal damage. However, the importance of early diagnosis of VUR has been questioned. Moreover, most studies have few patients with high-grade VUR. Hence, we retrospectively analyzed a large cohort of patients with primary high-grade and low-grade VUR and assessed risk factors for renal damage and clinical morbidity. We included patients (<18 years) at diagnosis with low-grade (1-3) or high-grade (4-5) primary VUR and noted their clinical history and presence of hypertension, low eGFR (<60ml/in/1.73m2), renal scarring (focal or generalised) and reduced differential renal function (DRF; <45%). Risk factors were assessed (in patients and renal units) by logistic regression and generalised estimating equation. Of 399 primary VUR patients, 255 (64%) had high-grade VUR. Indications for voiding cystourethrogram were recurrent UTI (38%), first UTI (28%) and antenatal hydronephrosis (17%). At diagnosis, 252 (65%) had renal scars (focal in 170 [44%], generalised in 82 [21%]), and 188 (47%) had reduced DRF. High-grade VUR patients were more likely than low-grade VUR patients to have renal scarring (75% vs. 49%, p<0.01), low eGFR (23% vs. 13%, p=0.04) and significant hypertension (26% vs. 13%, p=0.02). High-grade VUR was associated with generalised scars (odds ratio [OR] 11, p<0.001), focal scars (OR 3.1, p<0.001) and reduced DRF (OR 2.3, p<0.001) shown in the table. Male sex was a risk factor for generalised scars (OR 2.3, p=0.005). Focal scars were associated with recurrent UTIs (OR=1.8, p=0.004) and reduced DRF (OR 1.4, p=0.027). Patients with multiple focal scars were diagnosed at an older age (2 years [1,4] than those with single scars (1.5 years [1,4] or no scars (1 year [0, 3]), p=0.04). The prevalence of renal damage and clinical morbidity at VUR diagnosis was higher than other studies. High-grade VUR patients had a greater prevalence of renal damage, low eGFR and hypertension than low-grade VUR patients and was a risk factor for focal scars, generalised scars and reduced DRF. Focal scars were independently associated with recurrent UTI. Those with multiple scars were diagnosed later than those with single scars or no scars. High-grade VUR was associated with renal damage and clinical morbidity. Our study highlights the importance of diagnosing VUR early to identify patients who may warrant long-term follow-up and intervention to minimize morbidity.

Utility of Urinary Biomarkers Neutrophil Gelatinase-Associated Lipocalin and Kidney Injury Molecule-1 as a Marker for Diagnosing the Presence of Renal Scar in Children with Vesicoureteral Reflux (VUR): A Cross-Sectional Study.

Aim:To explore the possibility of using urinary biomarkers neutrophil gelatinase-associated lipocalin (NGAL) and kidney injury molecule-1 (KIM-1) to assess the presence of renal scars in children with Vesicoureteric Reflux (VUR).Materials and Methods:This cross-sectional study was conducted in 94 children aged 0–16 years diagnosed with VUR in the Department of Pediatric Surgery, JIPMER. Urinary biomarkers were measured using the enzyme-linked immunosorbent assay kits, normalized with urinary creatinine (Cr) and compared with severity of VUR (low grade [I and II] and high grade [III, IV, and V]), presence or absence of renal scar in VUR patients and severity of renal scar. Independent Student's t-test, Mann–Whitney U-test, and analysis of variance Kruskal–Wallis test were used for comparison, and receiver operating characteristic (ROC) curve analysis for predicting the accuracy of biomarkers in detecting the presence of renal scars.Results:The median urinary NGAL (uNGAL) value was higher in children with renal scar (1.49 ng/mL) than those without renal scar (0.58 ng/mL) and was statistically significant (<0.001). Whereas median uNGAL/Cr was higher in children with renal scar (0.07) than those without renal scar (0.03) but was not statistically significant (P = 0.06). Urinary KIM-1 and urinary KIM-1/urinary Cr (uKIM-1/Cr) was not found to be a significant predictor of renal scar. The difference of uNGAL/Cr was comparable between the grades of renal scar but was not statistically significant. On ROC curve analysis, uNGAL had area under the ROC curve (AUC) of 0.769 with 71% of both specificity and sensitivity, whereas uNGAL/Cr was found to be a poor predictor of renal scar with AUC of 0.611, 60% sensitivity, and 61.2% specificity.Conclusion:uNGAL can serve as a noninvasive marker for diagnosing the presence of renal scar in children with VUR and a multicentric more extensive cohort study may be needed to strengthen or negate its role.

Evaluation of platelet indices in children with renal scarring based on diagnostic accuracy criteria and Cohen's kappa.

Renal scarring is a significant complication in recurrent urinary tract infections (UTIs) in children that can lead to hypertension and end-stage renal disease. The present study evaluates whether platelet indices may be predictive of renal scarring. Sixty-nine patients aged 1-18 years with recurrent UTIs, whose medical records were reviewed to collect data on the presence of upper/lower UTIs and the results of scintigraphic investigations with 99m-technetium dimercaptosuccinic acid, were included in the study. The platelet, platelet indices (mean platelet volume [MPV]), platelet distribution width, plateletcrit, and C-reactive protein (CRP) values of the patients during UTI episodes were reviewed retrospectively. Mean platelet volume and CRP values were higher in the renal scarring group than in the non-renal scarring group (P < 0.001 and P = 0.003, respectively). Increases in MPV and CRP values were independent risk factors for renal scarring (OR = 5.781 [1.431-23.347] and OR = 1.922 [1.77-3.141], respectively). The sensitivity, specificity, positive and negative predictive values, and diagnostic odds ratio values of MPV at a cut-off of >8.2 fL for renal scarring discrimination were 62.5%, 88.89%, 75.00%, 81.63%, and 13.33 [1.35-3.83], respectively. The sensitivity, specificity, positive and negative predictive values, and diagnostic odds ratio values of CRP at a cut-off of 1.97 mg/L for renal scarring were 58.33%, 91.11%, 77.78%, 80.39%, and 14.35 [1.36-3.97], respectively. Both MPV and CRP can be used as predictive markers for renal scarring. While MPV had higher sensitivity, CRP had a higher specificity and diagnostic odds ratio in predicting renal scarring.

Математический анализ индивидуальных профилей биомаркеров повреждения почек у детей с пузырно-мочеточниковым рефлюксом

Objective. To assess the severity of lesions to renal parenchyma in children with grade II–IV vesicoureteral reflux (VUR) using hierarchical clustering based on the analysis of individual profiles of urinary biomarkers. Patients and methods. In this study, we evaluated the excretion of urinary biomarkers of inflammation (IL-8, IL-18, MCP-1), angiogenesis (VEGF), and fibrogenesis (TGF-β1) and compared them with clinical and demographic parameters of 65 patients with grade II–IV VUR aged 1 to 17 years (mean age 4.9 ± 3.1 years) with a normal glomerular filtration rate (GFR). The control group comprised healthy children without kidney diseases (n = 25). We used hierarchical clustering (construction of dendrogram using the Ward's method) for all biomarkers. Results. All patients, regardless of their age, gender, and VUR severity demonstrated a pathological profile of urinary biomarkers excretion, including IL-8, IL-18, MCP-1, VEGF, TGF-β1 (p &gt; 0.05). Using cluster analysis, we divided all patients into three subgroups (clusters) depending on the similarity of their individual biomarker profiles. We identified three main patterns of biomarkers that were associated with different severity of tubulointerstitial nephritis (TIN). The first pattern (I) with low levels of excretion of all biomarkers (p &lt; 0.001) correlated with mild TIN and was observed in 61.5% of children. The second pattern (II) with average excretion of IL-8, IL-18, MCP-1, TGF-β1 (p &lt; 0.01) and high VEGF excretion (p &lt; 0.001) was associated with moderate TIN and was observed in 32.2% of patients. The third pattern (III) with elevated excretion of IL-8, IL-18, MCP-1 and VEGF (by 2.5–17 times compared to patterns I and II) (p &lt; 0.01) correlated with severe TIN and was found in 6.1% of patients. Patients with the same VUR grades demonstrated different biomarker patterns. Conclusion. Hierarchical clustering enables comparison of individual profiles of urinary biomarkers with identified patterns, as well as their stratification into groups according to tubulointerstitial nephritis severity, which often remains undiagnosed with visualization techniques alone. Key words: children, cluster analysis, urinary biomarkers, vesicoureteral reflux, reflux nephropathy, tubulointerstitial nephritis

Prevalence of Renal Failure in Children and the Need for Dialysis in Paediatric Nephrology in a Developing Country

Background: Renal failure is among the major visceral failures responsible for morbidity and mortality in children. Epidemiological data on renal failure in children are limited in sub-Saharan Africa, including Senegal. We conducted this study to assess the prevalence of renal failure (RF) and the need for dialysis in the paediatric nephrology unit. Patients and methods: This was a retrospective and descriptive study in the pediatric nephrology unit from 1st January 2020 to 30 June 2021, including children with acute or chronic RF. The need for dialysis was judged to be met by its effectiveness in face of an indication. The data collected were analysed on sphinx plus 2017 software. Results: The prevalence of RF was 60% (n/N = 132/220). RF was acute in 59% (n/N = 78/132) of cases. The mean age was 6.53 ± 4.77 years with a sex ratio of 1.8. The mean serum creatinine level was 27.22 mg/L (240.9 μmol/L) and BUN at 0.85 g/L. The aetiologies were dominated by prerenal AKI (Acute Kidney Injury) complicating nephrotic syndrome (NS) in 37.2% (n/N = 29/78) and dehydration due to stomach flu in 17.6% (n/N = 9/51). Acute post-infectious glomerulonephritis including group A streptococcus and plasmodium falciparum accounted for 16.7% (n = 13/78) of intrinsic AKI. The need for dialysis was unmet in 50% (n/N = 7/14) with a mortality of 14.1% (n/N = 11/78). The mean age of the patients with chronic RF was 8.68 ± 4.74 years with a sex ratio of 2.6. The mean serum creatinine level was 36.56 mg/L (323.5 μmol/L) and the BUN level was 0.99 g/L. Half of the children were classified as having CKD stage II (early stage). The aetiologies were dominated by primary focal and segmental glomerulosclerosis (FSGS), 53.7% (n/N = 29/54), renal hypoplasia, 22.2% (n/N = 12/54) and reflux nephropathy, 29.4% (n/N = 5/17). The need for dialysis was unmet in 46.1% (n/N = 6/13). The overall mortality of chronic kidney disease (CKD) with RF was 29.6% (n/N = 8/27). Conclusion: The prevalence of RF was high in the unit. Most aetiologies of AKI were accessible to prevention. Only half of the children had access to free dialysis, hence the need for a dedicated pilot dialysis centre.

Risk factors for breakthrough urinary tract infection in children with vesicoureteral reflux receiving continuous antibiotic prophylaxis.

BackgroundTo investigate the risk factors for breakthrough urinary tract infection (BT-UTI) in children with vesicoureteral reflux (VUR) receiving continuous antibiotic prophylaxis (CAP).MethodsThis was a single-centre cohort study (January 2016 to December 2019). The clinical data of 256 children with grade I–V VUR receiving CAP were analysed. In this study, exposure variables were sex, younger age at the initial diagnosis of UTI ≤12 months, high-grade VUR, bilateral VUR, aetiology, presence of renal scarring at the initial diagnosis, presence of renal function impairment at the initial diagnosis, ultrasound abnormalities, antibiotic used and bladder and bowel dysfunction (BBD). Outcome was BT-UTI.ResultsBT-UTI occurred in 81 out of 256 children with grade I–V VUR who received CAP, an incidence of 31.64%. Univariate analysis showed that younger age at the initial diagnosis of UTI (≤12 months), bilateral VUR, renal scarring on the dimercaptosuccinic acid (DMSA) scan at the initial diagnosis of UTI and BBD were correlated with the occurrence of BT-UTI. Multivariate analysis showed that younger age at the initial diagnosis of UTI (≤12 months) [hazard ratio (HR): 4.629; 95% confidence interval (CI): 1.302–16.462], bilateral VUR (HR: 2.078; 95% CI: 1.084–4.022) and BBD (HR: 3.194; 95% CI: 1.243–8.206) were independent risk factors for the occurrence of BT-UTI.ConclusionsFor VUR children receiving CAP, younger age at the initial diagnosis of UTI (≤12 months), bilateral VUR, and BBD were independent risk factors for the occurrence of BT-UTI.

Artificial Intelligence Assessment of Renal Scarring (AIRS Study).

The goal of the Artificial Intelligence in Renal Scarring (AIRS) study is to develop machine learning tools for noninvasive quantification of kidney fibrosis from imaging scans. We conducted a retrospective analysis of patients who had one or more abdominal computed tomography (CT) scans within 6 months of a kidney biopsy. The final cohort encompassed 152 CT scans from 92 patients, which included images of 300 native kidneys and 76 transplant kidneys. Two different convolutional neural networks (slice-level and voxel-level classifiers) were tested to differentiate severe versus mild/moderate kidney fibrosis (≥50% versus <50%). Interstitial fibrosis and tubular atrophy scores from kidney biopsy reports were used as ground-truth. The two machine learning models demonstrated similar positive predictive value (0.886 versus 0.935) and accuracy (0.831 versus 0.879). In summary, machine learning algorithms are a promising noninvasive diagnostic tool to quantify kidney fibrosis from CT scans. The clinical utility of these prediction tools, in terms of avoiding renal biopsy and associated bleeding risks in patients with severe fibrosis, remains to be validated in prospective clinical trials.

Evaluation of the Relationship of the Time of Vesicoureteral Reflux Between Renal Scar Development and Endoscopic Treatment Success in Early Childhood

INTRODUCTION: Vesicoureteral reflux (VUR) is an important cause of urinary tract infection and chronic renal disease. Voiding cystourethrography (VCUG) is the gold standard diagnostic test in the diagnosis of VUR. In recent years, new parameters related to VCUG have been more objectively studied to evaluate the clinical prognosis. It is aimed to evaluate the effect of reflux time in primary VUR in terms of predicting endoscopic treatment success and treatment timing in VUR management. METHOD: In our study, the records and imaging findings of children with primary VUR who underwent VCUG examination between 2012 and 2019, who were treated with endoscopic injections, were retrospectively reviewed. Forty one children (67 renal units) were included in our study. Patients with preoperative VCUG, urinary ultrasonography, dimercaptosuccinic acid (DMSA) renal scan, and post-operative control VCUG were included in this study. RESULTS: Patients with preoperative VUR grade 1-2 were divided into two groups as “low grade” and patients with stage 3-4-5 as “high grade”. In the general patient population, endoscopic success rates in terms of renal unit deficit were found to be 46.3% (31/67). When the subgroup was analyzed, the endoscopic treatment success rate was 72.2% (13/18) in the low-grade group, versus 36.7% (18/49) in the high-grade group (p = 0.010). In the multivariate logistic regression analysis performed to identify independent predictors of scarring, reflux degree and reflux time were found to be independent predictors of scarring. CONCLUSION: In our study, we found that in VCUG evaluated preoperatively, VUR time as well as VUR grade were effective on endoscopic success rate and scar development. Based on these results, it could be thought that VUR time may be effective in selecting the best candidates for surgery and in the management and timing of treatment of VUR patients.

Duplex Collecting System of Right Kidney in 3-Year-Old Child: A Case Report

<i>Background: </i>The duplex collecting system is one of the congenital anomalies of kidney and urinary tract. It occurs in 0.2-2% of the general population. It can remain asymptomatic or become symptomatic. Affected children may present with urinary tract infections. Treatment options include pharmacological and surgical approaches. <i>Case:</i> We reported a 3-year-old male child, who was referred to Sanglah Hospital with recurrent fever. From the physical examination, we found positive costovertebral angle tenderness. Urinalysis showed high leukocyte sediments (1655/field of view), positive urine culture (<i>Enterococcus gallinarum</i>), and decreased glomerular filtration rate (68.75 ml/minute/1.73 m²). Ultrasonography of the right kidney showed two pelvicalyceal systems with severe hydronephrosis of upper moiety. The intravenous pyelography showed the drooping lily sign in the right kidney. We diagnosed the patient with a complicated urinary tract infection caused by <i>Enterococcus gallinarum</i>, duplex collecting system of right kidney, chronic kidney disease stage II. Antibiotics were administered due to complicated UTI. Open heminephrectomy was done. The patient was discharged in stable condition. <i>Conclusion: </i>The duplex collecting system may cause recurrent urinary tract infection. It can be a risk factor for renal scarring and cause chronic kidney disease. Comprehensive diagnostic workup and multidisciplinary management are needed to promote a good clinical outcome.

Local recurrence of renal cell carcinoma after partial nephrectomy: applicability of the apparent diffusion coefficient of MRI as an imaging marker - a multicentre study.

PurposeThe goal of the study was an assessment of the diagnostic performance of diffusion-weighted images (DWI) and apparent diffusion coefficient (ADC) of magnetic resonance imaging (MRI) in distinguishing local recurrence (LR) of renal cell carcinoma (RCC) from benign conditions after partial nephrectomy.Material and methodsThirty-nine patients after partial nephrectomy for solid RCC were enrolled in the study. Patients were followed up using MRI, which included DWI sequence (b = 800 s/mm2). All patients with MRI features of LR were included in the main group (n = 14) and patients without such features – into the group of comparison (n = 25). Apparent diffusion coefficient (ADC) values of suspicious lesions were recorded. In all patients with signs of locally recurrent RCC, surgical treatment was performed followed by pathologic analysis.ResultsThe mean ADC values of recurrent RCC demonstrated significantly higher numbers compared to benign fibrous tissues and were 1.64 ± 0.15 × 10-3 mm2/s vs. 1.02 ± 0.26 × 10-3 mm2/s (p < 0.001). The mean ADC values of RCCs’ LR and benign post-op changes in renal scar substantially differed from mean ADC values of healthy kidneys’ parenchyma; the latter was 2.58 ± 0.05 × 10-3 mm2/s (p < 0.001). In ROC analysis, the use of ADC with a threshold value of 1.28 × 10-3 mm2/s allowed us to differentiate local recurrence of RCC from benign postoperative changes with 100% sensitivity, 80% specificity, and accuracy: AUC = 0.980 (p < 0.001).ConclusionsThe apparent diffusion coefficient of DWI of MRI can be used as a potential imaging marker for the diagnosis of local recurrence of RCC.

Case Report on Chronic Renal Failure in Adults

Introduction: CRF is either the presence of kidney damage for 3 months or longer. Kidney damage is defined as either pathologic abnormalities or markers of damage including abnormalities in blood or urine test or imaging studies. Chronic disease are defined broadly as conditions that last 1 year or more and require ongoing medical attention or limit activities of daily living or both. Chronic disease such as heart disease, cancer, and diabetes are the leading causes of death and disability in the individual. As renal function declines, the end products of protein metabolism (normally excreted in urine) accumulate in the blood. Uremia develops and adversely affects every system in the body the greater the buildup of waste products, the more pronounced the symptoms. The rate of decline in renal function and progression of end stage kidney disease is related to the underlying disorder.&#x0D; Main Symptoms of CRF: The main signs and symptoms-Fever/cough/cold/abdominal pain/vomiting/loose stool/edema/giddiness/back pain. Abnormal blood loss in urine test, high blood pressure, weight loss for no reason, low red blood cell count (anemia), nausea, metal taste in your mouth, loss of appetite.&#x0D; Diagnostic Evaluation: blood test: Hb-6.5gm%, total RBC count-3.5million/cu mm, HCT-28.4%, total WBC count-9.6/cu mm. monocytes-03%, granulocytes-85%, lymphocytes-10%,calcium-9.1mg/day, creatinine-urine test-71.8mg/dl, KFT- urea-111mg/dl, cretinine14.0, sodium 134mmol/l, potassium-6.5(pl. repeat), magnesium-2.4mmol/l, phosphorus-7.3mmol/l, RBS glucose-plasma random -222mmhg, uric acid -8.1mg/dl, urinary protein- 905mg/dl, bloodpressure-140/90mmhg.&#x0D; Therapeutic interventions: inj. Levoflox 500mg IV OD, inj. ctri 1gm IV BD X 5days, inj. Pan 40mg IV OD, inj. Emset 4mg IV OD, inj. Insulin m(30/70) 18u(BFF)-0-12u(BD) inj. EPO 10000 IU SC post dialysis once per week, tab. Nicardia 20mg TDS, tab. Febuxostat 40mg OD, tab. Shelcal 500mg OD, tab. autrin OD, tab. Sevelamer 400mg BD, tab. Envas 5mg HS, tab. met XL 25mg OD.&#x0D; Outcome: after treatment, the adult show improvement. His abdominal pain were relieved and his diabetes and hypertension were in control.&#x0D; Causes: Due to some disease of infection the kidney can’t do its works properly, the main cause of chronic renal failure is High blood pressure Blocked urinary tract. The chief causes of CRF include obstructive uropathy, primary glomerular diseases, reflux nephropathy and hypoplastic or dysplastic kidneys. Progressive hyperperfusion and hyerfilteration causes increasing glomerular injury and further renal damage. Symptoms of CRF is between 10-25% of normal. The four main causes of CRF are high blood pressure, chronic glomerulonephritis, high blood sugar, polycystic kidney disease.&#x0D; Conclusion: My patient was a known case of chronic renal failure and he had complaint of irritation abdominal pain, back pain, giddiness. After getting proper treatment his condition was better than previous condition.

Clinical and bacteriological profile of urinary tract infection in children at a tertiary care hospital

Background: Urinary tract infection (UTI) is common in children and is an important cause of morbidity. UTI at young age can lead to renal injury and scarring, and ultimately lead to end stage renal disease in adulthood. Aim of the study The objectives of this study were to study the clinical and bacteriological profile of UTI in children.Methods: This prospective study was done in Sher-E-Bangla medical college hospital, Barishal from January 2018 to July 2019. A urine sample was included in our dataset if it demonstrated pure growth of a single organism and accompanying antimicrobial susceptibility and subject demographic data were available.Result: UTI was more common in female (70.0%) than in male (33.0%). Half were in the age group 1-5 years. Fever was the most common presentation (64.0%) followed by abdominal pain (42.0%), dysuria /increased frequency (34%), decreased appetite (28%). Escherichia coli was the most common (64%) bacterial isolate followed by Klebsiella sp. (20.0%) and Proteus sp. (14.0%). E. coli was highly sensitive to ofloxacin, cefotaxime and amikacin (94.0%). Klebsiella was 100% sensitive to ciprofloxacin and amikacin. Greater degree of resistance was seen to ampicillin, cotrimoxazole and nalidixic acid.Conclusions: Though various microorganisms are responsible for UTI in children, E. coli is the most common causative agent. Antimicrobial resistance has already emerged against many antibiotics, making empiric treatment of these infections challenging.

Risk Factors for the Development of Febrile Recurrences in Children with a History of Urinary Tract Infection

To identify risk factors for febrile recurrence of urinary tract infections (UTIs) in children with a history of UTI. We included 500 children aged 2-72months with a history of UTI who were followed prospectively for approximately 2years in the context of 2 previously conducted studies (Randomized Intervention for Children with Vesicoureteral Reflux and Careful Urinary Tract Infection Evaluation). We identified significant risk factors for febrile recurrences among children not receiving antimicrobial prophylaxis using univariate and multivariate logistic regression. On univariate analysis, non-Black race, febrile index UTI, bowel-bladder dysfunction, grade IV vesicoureteral reflux, renal scarring at baseline, and renal-bladder ultrasound abnormalities were associated with febrile recurrence. On multivariate analysis, the following variables independently increased the odds of febrile recurrences (OR; 95% CI): non-Black race (7.1; 1.5-127.9), bowel-bladder dysfunction (2.6; 1.1-5.3), febrile index UTI (2.5; 1.1-6.9), abnormalities on renal-bladder ultrasound scan (2.6; 1.2-5.6), grade IV vesicoureteral reflux (3.9; 1.4-10.5), and renal scarring at baseline (4.7; 1.2-19.1). Non-Black race and grade IV vesicoureteral reflux increased the odds of febrile recurrence of UTI. Although our findings should stimulate other studies to further explore the relationship between race and UTIs, given that the link between race and UTI recurrence is unclear, race should not be used to make decisions regarding management of children with a UTI.

Is there a relationship between renal scarring and neutrophil-to-lymphocyte ratio in patients with vesicoureteral reflux?

Vesicoureteral reflux (VUR) exacerbates the risk of renal scarring by establishing a ground for pyelonephritis. It is known that the inflammatory process is more influential than the direct damage caused by bacterial infection in the development of renal scars after pyelonephritis. Therefore, the present study aims to investigate the relationship between renal scarring and systemic inflammatory markers in patients with VUR. Hundred and ninety-two patients (116 females, 76 males) diagnosed with VUR were divided into two groups based on the presence or absence of renal scarring and into three groups according to the grade of VUR (low, moderate and high). Neutrophil count, lymphocyte count, mean platelet volume (MPV) and neutrophil-to-lymphocyte ratio (NLR) were compared among the groups. Of the 192 patients, 102 had renal scarring. The age and gender distribution did not differ significantly between the groups with and without renal scarring (p > 0.05). However, the grade of reflux and lymphocyte count were significantly higher in the group with renal scarring (p < 0.05), and the NLR was significantly lower in the group with renal scarring (p < 0.05). The lymphocyte count was significantly higher (p < 0.05) and NLR was significantly lower in the high-grade VUR group (p < 0.05). However, MPV values did not differ significantly (p > 0.05) between the groups. NLR can be used to predict renal scarring in patients with VUR, especially in the period of 3-6 months after the first attack of infection, and may even serve as a candidate marker for treatment selection. However, larger series and prospective studies are needed.