The organization of Kidney Transplantation Services at Ramathibodi Hospital: fourteen years experience on waiting list, kidney donors and kidney transplantation.

The Kidney Transplantation Program at Ramathibodi Hospital was established in 1985. By the end of 1998, there were 1,614 patients on the cumulative waiting list. The first kidney transplantation (KT) was started in 1986 by using kidney from living-related donor (LD) while cadaveric KT (CD-KT) was started in 1987. A total of 528 KT were done, 278 cases (52.7%) were CD-KT and 250 cases (47.3%) were LD-KT. Six patients had two kidney transplants. 278 kidneys were donated from 189 cadaveric donors. Fifty cadaveric donors (26.4%) were from Ramathibodi Hospital while the rest were from other hospitals and the Organ Donation Center, Thai Red Cross Society. For LD, 233 out of 250 (93.2%) were from living-related, more than 50 per cent of these donors were from siblings. 17 spousal donors have been accepted for KT at Ramathibodi Hospital since 1997. Concerning the recipient pools, 522 patients (32.3%) were transplanted, 123 patients (7.6%) died without KT, 111 patients (6.9%) underwent KT at other hospitals, and 78 patients (4.8%) changed to waiting lists at other hospitals. The rest were lost to follow-up. At present, only 265 patients are still actively waiting (send serum every month). The number of KT and living donors has gradually increased, whereas, the number of cadaveric donors has decreased. However, cooperation with the "Organ Donation Center" has improved the number of cadaveric donation in the last two years. Sufficient organ donations and an active working team will provide a good kidney transplant service for the patients.

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.

Pulmonary involvement in childhood systemic lupus erythematosus.

Twenty-four children (aged 6-15 years, M:F = 1:11) with systemic lupus erythematosus (SLE), who had respiratory symptoms, were retrospectively reviewed. Chest radiographs obtained from all patients revealed pleural effusion in 13, alveolar infiltration in 9, pericardial effusion and cardiomegaly in 6, interstitial infiltration in 4, hilar adenopathy in 3, lung abscess in 2 and pneumatocele with pneumothorax in 1. Etiologic organisms were identified in 7 cases; (3 cases of nocardia isolated from pleural effusion and sputum, 2 cases of tuberculosis, 1 case with staphylococcus aureus septicemia and 1 case with salmonella septicemia). All except one patient improved with medical treatment. One patient died from pneumonitis. Although pulmonary involvement is increasingly recognized in children with SLE, neither roentgenogram nor clinical findings were specific. The differentiation of pulmonary infiltrates caused by lupus lung disease from pulmonary infection should be carefully evaluated.

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.

Comparison of urine specific gravity values from total-solids refractometry and reagent strip method.

The comparison of specific gravity values of 561 urine samples from TS meter and reagent strip was made. The data were divided into two groups: group 1-less than 2+ protein contained urine samples and group 2--equal or more than 2+ protein contained urine samples. The results revealed that the specific gravity values from both methods in both groups were statistically different (p less than 0.01) but they were correlated at r = 0.84 (p less than 0.001) and r = 0.73 (p less than 0.001) in group 1 and group 2, respectively. It was concluded that the reagent strip is suitable for use as a screening test but it should not be considered when precise measurement is necessary.

The primary nephrotic syndrome in children at Ramathibodi Hospital: clinical and clinicopathological study.

Mesangial proliferative glomerulonephritis (MesPGN) is the most common histopathological finding of primary nephrotic syndrome in Thai children. Prediction of glomerular morphology is possible by the clinical characteristics: the age at onset older than 6 years old, occurring mostly in males, with or without hematuria, no hypertension, normal serum creatinine level, response to initial corticosteroid therapy but frequent relapses. Epidemiological study pertaining to associated environmental factors and immunological response of Thai children is needed.

Urinary N-acetyl-beta-D-glucosaminidase (NAG) in aminoglycoside nephrotoxicity.

Urinary N-acetyl-beta-D-glucosaminidase (UNAG) excretion was measured in 37 children before and during the treatment with aminoglycosides at the Department of Pediatrics, Ramathibodi hospital from July 1 to October 31, 1986. There were 20 males and 17 females whose ages ranged from 15 days - 15 years. Twelve were in postoperative status, 11 with respiratory tract disease, 11 with urinary tract disease and 3 in the miscellaneous group. Aminoglycosides were given alone in 11 patients, combined with cloxacillin in 14 and with other antibiotics in 12 patients. The duration of aminoglycoside given ranged from 5-27 days (mean +/- SD = 11.5 +/- 5.5 days). Clinical nephrotoxicity was detected in 12 patients (32.4%), of which 7 were males and 5 were females, 4 were less than 1 year old. It appeared 4-9 days (mean +/- SD = 5.8 +/- 1.6 days) after initiation of the treatment. Variation in age, sex, initial UNAG excretion and antibiotic combination were not associated with increased risk of nephrotoxicity. Thirty patients had elevated baseline UNAG excretion from 1-14 times higher than the normal value. UNAG excretion was increased 0.23-5.57 fold in all patients after 24 hours of treatment. In those with clinical nephrotoxicity, the enzymuria rose more than one fold in all of them (sensitivity 100%, specificity 68%, accuracy 78.4%) and this was detected 2-7 days (mean +/- SD = 3.8 +/- 1.6 days) prior to the rise of serum creatinine.(ABSTRACT TRUNCATED AT 250 WORDS)