Transfusion requirements in patients with dengue hemorrhagic fever.

Dengue viruses are endemic in Thailand and Southeast Asian countries. A retrospective study of 175 patients with dengue virus infection admitted at the Department of Pediatrics, Ramathibodi Hospital in 1997 was carried out. Fifteen and 160 patients were clinically diagnosed with dengue fever and dengue hemorrhagic fever (DHF), respectively. DHF was commonly found in patients whose ages ranged from 10 to 14 years. The mean body weight was at the 54th percentile for age. In the management, 10.6% of patients with DHF required blood component therapy which included platelet concentrate (64.7%) in patients who exhibited active bleeding, packed red cells (47%) in patients who exhibited a rapid drop in the hematocrit and fresh frozen plasma (29.4%) in patients with circulatory failure who did not respond to intravenous fluid. The transfusion requirement was significantly correlated with the occurrence of bleeding (p < 0.008) and bleeding in the gastrointestinal tract (p < 0.0001) but not correlated with the number of platelet counts (p = 0.207). As a result, physicians in charge should be aware of the transfusion requirement and communicate this to the blood bank in advance for the preparation of appropriate blood components.

Comparison of urine anion gap, urine osmolal gap and modified urine osmolal gap in assessing the urine ammonium in metabolic acidosis.

Twenty-four hour urine and spot urine samples from 29 patients with metabolic acidosis were collected for evaluation of urine ammonium in relation to urine anion gap, urine osmolal gap (OG) and modified urine osmolal gap (MOG). Their underlying diseases included SLE in 8, RTA in 7, CRF in 6, RPGN in 2 (one with SLE), Lowe syndrome in 2, on acetazolamide in 2, gastroenteritis in 2, and CAH in one. Twenty-three patients had normal serum anion gap (< 14 mmol/L). Their mean CO2 was 13.77 (9.4-17.9) mmol/L, net acid excretion (NAE) was 33.18 +/- 35.36 mmol/24 hour, NH+4 excretion was 29.16 +/- 31.97 mmol/24 hour. Neither the 24-hour urine nor spot urine anion gap correlated with corresponding urine NH+4 with or without adding urine HCO-3 in the calculation. Spot urine NH+4 correlated well with urine OG (r2 = 0.82, p < 0.001) and less with MOG (r2 = 0.339, p < 0.006). The urine osmolality was well correlated with the sum of 2 (Na+ + K+ + NH+4) + urea for both spot (r2 = 0.990, p < 0.001) and 24 hour urine (r2 = 0.907, p < 0.001) collection. Twenty-four hour urine NH+4 did not correlate with the OG or the MOG. There was no correlation between spot urine NH4/Cr ratio and 24 hour urine NH4/Cr ratio (r2 = 0.243, p = 0.53) nor between spot NAE/Cr ratio and 24 hour urine NAE/Cr ratio (r2 = 0.380, p = 0.014). Therefore in the presence of low urine NH+4 (< 100 mmol/L), urine osmolal gap may be used to determine urine NH+4 indirectly with good correlation. Twenty-four hour urine collection is still necessary to assess renal acidification.

The efficacy of intravenous pulse cyclophosphamide in the treatment of severe lupus nephritis in children.

BACKGROUND: The intermittent intravenous cyclophosphamide in the treatment of lupus nephritis in adults is well tolerated and associated with clinical improvement and long term stability of renal function. However, there are few reports about the efficacy of intravenous pulse cyclophosphamide (IPC) of severe lupus nephritis in children. OBJECTIVE: To evaluate the clinical efficacy, renal function, renal outcome and complications of IPC therapy in children with severe lupus nephritis. METHOD: Prospective study. PATIENTS: Children with severe lupus nephritis have been followed-up for at least 6 months. Treatment regimen: Intravenous pulse cyclophosphamide 0.5-0.75 g/m2 given monthly for 6 months with subsequent doses given at 2-3 months interval up to 3 years and combined with low dose oral prednisolone therapy. RESULTS: Thirty-one children (mean age: 12.31 +/- 2.03 years; female:male = 24:7) with severe lupus nephritis received IPC therapy. 24 out of 28 patients (85.7%) had diffuse proliferative glomerulonephritis. After 3 months of treatment, most patients were clinically improved as evidenced by significant improvements in 24-hour urine protein, creatinine clearance, serum creatinine, BUN, serum albumin and C3 level. These improvements were sustained up to 18 months and were accompanied by a significant reduction in prednisolone dosage. Renal outcome at the last follow-up (range = 6-76 months) demonstrated that twelve patients (38.7%) had complete remission, 18 patients (58.0%) still had significant proteinuria and only one had serum creatinine of 1.6 mg/dl at 42 months. One child progressed to end stage renal diseases during IPC therapy. Five patients had severe infections during the treatment resulting in one death. Hemorrhagic cystitis and malignancies were not found. CONCLUSION: Treatment of severe lupus nephritis in children with intravenous pulse cyclophosphamide is associated with favorable short term results. Severe infections are the major complications.

Single daily dose of gentamicin in the treatment of pediatric urinary tract infection.

Fourty-nine patients aged 6 months to 12 years old with suspected urinary tract infection (UTI) were evaluated in this open randomized study. Twenty-seven patients received gentamicin 4.5 mg/kg/d once daily (OD group) and 22 patients received the same daily dose in three divided doses (TID group) for 3 days before being switched to amoxy-clavulanic acid. Ninety-six per cent (26/27) of the OD group had peak gentamicin within therapeutic level while 40 per cent (9/22) of the TID group had peak gentamicin within therapeutic level. One in OD group had high gentamicin level due to technical error in obtaining blood sample. None in neither group had trough level in toxic level. Only 24 patients had confirmed UTI and were evaluated for clinical efficacy and toxicity. Demographic data were the same in both groups except there were more males in OD group (8:3 vs 4:9). Patients in OD group became afebrile earlier than TID group (8.69 vs 15.31 hours) but no statistically significant difference. All patients had negative urine culture results within 48 hours. None had clinical nephrotoxicity in both groups. More patients in TID group had laboratory nephrotoxicity (5/11 vs 2/13) but no statistically significant difference. We conclude that gentamicin can be given safely and efficiently as single daily dose or thrice daily but more cost effective and less time consuming in once daily dose.

Effects of tuna fish oil on hyperlipidemia and proteinuria in childhood nephrotic syndrome.

This is a randomized, double-blind, placebo-controlled, cross-over study to determine whether tuna fish oil decreased hyperlipidemia and proteinuria in children with steroid-resistant nephrotic syndrome. Five boys were supplemented with both 4 grams of tuna fish oil and placebo in a randomized order for 8 weeks of each treatment separated by 6-week washout period. The results showed no statistically significant difference in serum creatinine, triglyceride, cholesterol, urine protein and creatinine clearance between fish oil supplemented group and placebo group. Small sample size, low dosage, short duration of supplementation and wash-out period are among the important limitations in this study. Further study should be performed to identify the effects of fish oil on this entity in nephrotic syndrome.

Primary vesicoureteric reflux in Thai children with urinary tract infection.

Four hundred and forty-three pediatric patients were analysed retrospectively for GU anomalies especially for primary VUR. Genito urinary tract anomalies were found in 46 per cent of investigated patients. Primary VUR was found in 29 per cent of patients who had GU anomalies and were the most common anomalies found. The GU anomalies were found more in younger males, and older females. Low to medium grade VUR tended to have spontaneous resolution and correlated well with degrees of controlling infection. In high grade VUR, fewer patients may have spontaneous resolution, surgery can correct the reflux but not the progression of the damage.

Rapidly progressive glomerulonephritis in Thai children.

Sixteen children with extensive crescentic glomerulonephritis and rapid renal deterioration were selected from 476 patients with glomerulopathy for study. The patients (1-14 yr, M:F = 5:11) presented with edema, oligoanuria, hypertension, gross hematuria and uremic symptoms in 81, 62, 62, 56 and 50 per cent, respectively. The mean Scr was 804 (+/- 436) micromole/L and BUN 38 (+/- 13.4) mmole/L. Anemia was found in 100 per cent, hematuria in 100 per cent, heavy proteinuria 75 per cent, hypoalbuminemia 40 per cent, hypercholesterolemia 38 per cent and low C3 40 per cent. The underlying causes of RPGN included idiopathic 9, PSAGN 6 and LE 1. Eight patients recovered with normal or slightly elevated Scr while the diseases progressed to ESRD in 8 patients. Idiopathic RPGN and extensive (greater than 80%) crescentic glomerulonephritis correlated with a poor prognosis.

Primary peritonitis in childhood nephrotic syndrome: a changing trend in causative organisms.

Three hundred and forty-seven children with primary nephrotic syndrome were analysed retrospectively, there were 55 episodes of peritonitis in 35 patients. Bacterial agents were identified in 60 per cent of the 55 episodes. Gram-positive cocci and gram-negative bacilli were found in equal numbers, with a definite increasing trend of gram-negative bacilli over the last 4 years. There was no predisposing factor of peritonitis regarding age, sex and renal pathology in relation to the development of peritonitis.

Genitourinary tract anomalies in Thai children with urinary tract infection.

One hundred and forty-three pediatric patients with initial documented UTI were analysed retrospectively. E. coli was the most common organism found in uncomplicated cases. Forty-six per cent of 110 patients who had radiologic evaluation had genitourinary tract anomaly with higher frequency in boys during the infancy period and girls during the early childhood period. Primary VUR was found in 11 per cent of patients mainly in infancy with an equal number among boys and girls. We conclude and strongly advise that radiologic evaluation should be done in all children with UTI, especially if they are younger than 5 year old.

Acute glomerulonephritis in children: a prospective study.

Fifty-six patients with acute glomerulonephritis were studied prospectively during 1984. Their ages ranged from 10 months to 14 years old with the peak age range between 5 to 9 years. Most of them had edema, hypertension, hematuria with or without proteinuria and had low serum complement. Azotemia was found in 45 per cent of the cases. Serologic evidence for streptococcal infection was positive in 68 per cent and only 6 per cent had positive culture. Edema and hypertension were all resolved within 2 weeks. All patients that were followed up had normal serum complement by the 6th week, normal BUN, Scr by one year. The hematuria disappeared by 6 months and proteinuria by 2 months in 50 per cent of the cases. By the 4th year only one patient had microscopic hematuria and mild proteinuria with normal serum creatinine, normotension and no edema. In conclusion, in Thailand AGN is still a common kidney disease in children but with prompt and proper treatment its prognosis is still very good.