Etiology and Outcome of Community-Acquired Acute Kidney Injury in Pediatric Inpatients

Objective: To estimate the etiology, outcome, and risk factors for mortality in children with community-acquired acute kidney injury (CA-AKI). Methods: Between October, 2020 and December, 2021, consecutive hospitalized children aged 2 mo-12 years with a minimum 24 hours of stay, and at least one serum creatinine level measured at or within 24 hours of hospitalization were prospectively enrolled. CA-AKI was labelled in children with an elevated serum creatinine level at admission and subsequent fall during hospitalization. Results: Of 2780 children, 215 were diagnosed as CA-AKI (7.7%, 95% CI 6.7-8.6). Diarrhea with dehydration (39%) and sepsis (28%) were the most common causes of CA-AKI. 24 children (11%) died during hospitalization. Requirement of inotropes was an independent predictor of mortality. Out of 191 children discharged, 168 (88%) had complete renal recovery. At 3 months, out of 22 children without complete renal recovery, 10 progressed to chronic kidney disease (CKD), with 3 becoming dialysis dependent. Conclusions: CA-AKI is common in hospitalized children, and is associated with increased risk of progression to CKD, especially in those with incomplete renal recovery.

Identification of Probable Urinary Tract Infection in Children Using Low Bacterial Count Thresholds in Urine Culture

Objectives: To assess the proportion of children, symptomatic for urinary tract infection (UTI), with urine culture showing single bacterial species >104 CFU/mL, and to compare patient and disease characteristics between children having low counts (from >104-105 CFU/mL) and those with counts >105 CFU/mL. Methods: Prospective observational study, enrolling symptomatic children aged 1 month to 12 years. Mid-stream clean-void or catheter collected urine were cultured. Children with single species >104 CFU/mL were scheduled for imaging studies, following age criteria of Indian Society of Pediatric Nephrology guidelines. The main outcome was proportion with single bacterial species >104 CFU/mL in urine culture. Results: Of 216 children (132 males) with median (IQR) age of 24 (12, 48) months, 38 (17.6%) showed single species growth >104 CFU/mL. Of these, 29 (13.4%) were diagnosed as UTI at cutoff >105 CFU/mL, and an additional 9 (4.2%) were found to have ‘probable low-count UTI’ (from >104 to 105 CFU/mL). One child in the latter group had bilateral hydroureteronephrosis, vesico-ureteral reflux and renal scarring. There was largely no difference in parameters between children with low counts and those with counts >105 CFU/mL. Conclusion: An additional proportion of symptomatic children with probable urinary tract infection and possible underlying urological abnormalities may be identified by lowering bacterial colony count cutoff to >104 CFU/mL, in clean-voided and catheter-based urine samples.

Clinico-Etiologic Profile of Macroscopic Hematuria in Children: A Single Center Experience

Objective: To study the demographic, clinical and etiological profile of macroscopic hematuria in children presenting to a tertiary care hospital. Methods: This prospective observational study, conducted between January, 2018 and December, 2019, enrolled children aged 3 months to 12 years, presenting with gross hematuria. Results: Of the 62 children (44 males) enrolled, (mean (SD) age of 7.3 (2.6) years), glomerular hematuria was seen in 59.7%. Post-infectious glomerulonephritis was the commonest etiology of glomerular hematuria; hypercalciuria and renal calculi predominated among non-glomerular hematuria. After a median (IQR) follow up of 8 (6,14.2) months, microscopic hematuria persisted in 10 (7, glomerular hematuria) children. The median time to resolution of gross as well as microscopic hematuria tended to be longer in glomerular etiologies. Conclusion: Majority of children with gross hematuria had glomerular etiologies, thus requiring monitoring and follow-up.

Indian Academy of Pediatrics Guidelines on the Fast and Junk Foods, Sugar Sweetened Beverages, Fruit Juices, and Energy Drinks

Justification: In view of easy availability and increasing trend of consumption of fast foods and sugar sweetened beverages (fruit juicesand drinks, carbonated drinks, energy drinks) in Indian children, and their association with increasing obesity and related non-communicable diseases, there is a need to develop guidelines related to consumption of foods and drinks that have the potential toincrease this problem in children and adolescents. Objectives: To review the evidence and formulate consensus statements related toterminology, magnitude of problem and possible ill effects of junk foods, fast foods, sugar-sweetened beverages and carbonated drinks;and to formulate recommendations for limiting consumption of these foods and beverages in Indian children and adolescents. Process:A National Consultative group constituted by the Nutrition Chapter of the Indian Academy of Pediatrics (IAP), consisting of variousstakeholders in private and public sector, reviewed the literature and existing guidelines and policy regulations. Detailed review ofliterature was circulated to the members, and the Group met on 11th March 2019 at New Delhi for a day-long deliberation on framing theguidelines. The consensus statements and recommendations formulated by the Group were circulated to the participants and aconsensus document was finalized. Conclusions: The Group suggests a new acronym ‘JUNCS’ foods, to cover a wide variety ofconcepts related to unhealthy foods (Junk foods, Ultra-processed foods, Nutritionally inappropriate foods, Caffeinated/colored/carbonated foods/beverages, and Sugar-sweetened beverages). The Group concludes that consumption of these foods and beveragesis associated with higher free sugar and energy intake; and is associated with higher body mass index (and possibly with adversecardiometabolic consequences) in children and adolescents. Intake of caffeinated drinks may be associated with cardiac and sleepdisturbances. The Group recommends avoiding consumption of the JUNCS by all children and adolescents as far as possible and limittheir consumption to not more than one serving per week. The Group recommends intake of regional and seasonal whole fruits over fruitjuices in children and adolescents, and advises no fruit juices/drinks to infants and young children (age <2 y), whereas for children aged 2-5 y and >5-18 y, their intake should be limited to 125 mL/day and 250 mL/day, respectively. The Group recommends that caffeinatedenergy drinks should not be consumed by children and adolescents. The Group supports recommendations of ban on sale of JUNCSfoods in school canteens and in near vicinity, and suggests efforts to ensure availability and affordability of healthy snacks and foods. TheGroup supports traffic light coding of food available in school canteens and recommends legal ban of screen/print/digital advertisementsof all the JUNCS foods for channels/magazines/websites/social media catering to children and adolescents. The Group further suggestscommunication, marketing and policy/taxation strategies to promote consumption of healthy foods, and limit availability and consumptionof the JUNCS foods

Prediction of Severe Acute Kidney Injury using Renal Angina Index in a Pediatric Intensive Care Unit

Objectives: To determine the proportion of children in a pediatric intensive care unit with apositive Day 0 Renal angina index who develop severe acute kidney injury (AKI) on Day 3;and to compare the predictive ability of the index with that of individual markers of renal injury,for the development of severe acute kidney injury. Design: Observational study. Setting:Pediatric intensive care unit of a tertiary-care hospital. Participants: Consecutive children, 1month to 12 years, admitted in Level 3 pediatric intensive care unit for a minimum of 8 hours,having weight and intake-output records, were eligible. Children known to have chronickidney disease or already in stage 2/3 acute kidney injury/dialysis were excluded.Procedure: Day 0 Renal angina index was calculated from the product of Risk Group score(Pediatric intensive care admission/Ventilation and inotropy) and Renal Injury score (fluidoverload over previous 8 hours or the % fall in estimated creatinine clearance from baseline).Renal angina index ≥8 was considered positive. Main outcome measure: The proportion ofchildren with positive Day 0 Renal angina index who develop severe AKI (Kidney DiseaseImproving Global Outcomes (KDIGO) ≥ Stage 2) on Day 3. Results: Of 162 enrolled children(median (IQR) age 10.5 (3,39) months), 86 (53%) had positive Renal angina index. On Day 3,a higher proportion of children with positive index developed severe AKI, compared tonegative group (RR 95.5; 95% CI 21.7,420.5; P<0.001). Day 0 positive Renal angina indexhad a sensitivity, specificity, positive predictive value and negative predictive value of 96.9%,75.5%, 72% and 97.4% respectively, for predicting severe AKI on Day 3. The ReceiverOperating Characteristic curve of Day 0 renal angina scores showed AUC of 0.90 (95% CI0.85, 0.95), better than the AUC obtained from either Day 0 serum creatinine or Day 0 percentfall in estimated creatinine clearance from baseline. Conclusion: Day 0 Renal angina indexpositivity is a promising tool to identify critically ill children with impending severe AKI.

Profile of Acute Kidney Injury in Hospitalized Children with Idiopathic Nephrotic Syndrome

Objective: To determine the incidence, risk factors and outcome of acute kidney injury (AKI)in hospitalized children with nephrotic syndrome. Methods: All consecutive hospitalizedchildren (aged 1-14 years) with diagnosis of nephrotic syndrome between February 2016 andJanuary 2017 were enrolled for the study.Children (aged 1-14 years) with features ofnephritis, underlying secondary causes of nephrotic syndrome as well as children admittedfor diagnostic renal biopsy and intravenous cyclophosphamide or rituximab infusion wereexcluded. Results: A total of 73 children (81 admissions) were enrolled; incidence of AKI was16% (95% CI, 9-23). On multivariate logistic regression analysis, furosemide infusion wasobserved as an independent risk factor for acute kidney injury (OR 23; 95% CI, 3-141;P<0.001). Out of 13 children with AKI, three died. Conclusions: Acute kidney injury inhospitalized children with nephrotic syndrome has high risk of mortality. Children receivingfurosemide infusion should be closely monitored for occurrence of acute kidney injury.

Fever with rash in a child in India.

Fever with rash is common among children and are seen by both dermatologists and pediatricians. Most of them are benign viral exanthems without much clinical significance. This article gives an overview of the infectious and noninfectious causes of fever with rash in children and how to diagnose them, with special emphasis on the Indian scenario as well. It also differentiates them from fever with rash caused by drugs. This review emphasizes that although benign in many cases, it is necessary to identify the signs of serious illnesses to prevent mortality or sequelae.

Should We Screen Children with Severe Acute Malnutrition for Celiac Disease.

The clinical features of severe acute malnutrition (SAM) often overlap with the common manifestations of celiac disease. In this observational pilot study, 76 children fulfilling the case definition of SAM were investigated for celiac disease, tuberculosis and HIV. Celiac disease was diagnosed in 13.1% of SAM children while tuberculosis and HIV were diagnosed in 9.3% and 4%, respectively.