Incidence and risk factors for major infections in hospitalized children with nephrotic syndrome / Incidência e fatores de risco para infecções graves em crianças hospitalizadas com síndrome nefróticas

ABSTRACT Introduction: Children with nephrotic syndrome are at increased risk of infections because of disease status itself and use of various immunosuppressive agents. In majority, infections trigger relapses requiring hospitalization with increased risk of morbidity and mortality. This study aimed to determine the incidence, spectrum, and risk factors for major infections in hospitalized children with nephrotic syndrome. Methods: All consecutive hospitalized children between 1-12 years of age with nephrotic syndrome were enrolled in the study. Children with acute nephritis, secondary nephrotic syndrome as well as those admitted for diagnostic renal biopsy and intravenous cyclophosphamide or rituximab infusion were excluded. Results: A total of 148 children with 162 admissions were enrolled. Incidence of major infections in hospitalized children with nephrotic syndrome was 43.8%. Peritonitis was the commonest infection (24%), followed by pneumonia (18%), urinary tract infection (15%), and cellulitis (14%), contributing with two thirds of major infections. Streptococcus pneumoniae (n = 9) was the predominant organism isolated in children with peritonitis and pneumonia. On logistic regression analysis, serum albumin < 1.5gm/dL was the only independent risk factor for all infections (OR 2.6; 95% CI, 1.2-6; p = 0.01), especially for peritonitis (OR 29; 95% CI, 3-270; p = 0.003). There were four deaths (2.5%) in our study, all due to sepsis and multiorgan failure. Conclusions: Infection remains an important cause of morbidity and mortality in children with nephrotic syndrome. As Pneumococcus was the most prevalent cause of infection in those children, attention should be paid to the pneumococcal immunization in children with nephrotic syndrome.

RESUMO Introdução: Crianças com síndrome nefrótica apresentam maior risco de infecções devido ao próprio status da doença e ao uso de vários agentes imunossupressores. Em grande parte, as infecções desencadeiam recidivas que exigem hospitalização, com risco aumentado de morbidade e mortalidade. Este estudo teve como objetivo determinar a incidência, o espectro e os fatores de risco para infecções graves em crianças hospitalizadas com síndrome nefrótica. Métodos: Todas as crianças hospitalizadas consecutivamente entre 1 e 12 anos de idade com síndrome nefrótica foram incluídas no estudo. Crianças com nefrite aguda, síndrome nefrótica secundária, bem como aquelas admitidas para biópsia renal diagnóstica e infusão intravenosa de ciclofosfamida ou rituximabe foram excluídas. Resultados: Foram cadastradas 148 crianças com 162 internações. A incidência de infecções graves em crianças hospitalizadas com síndrome nefrótica foi de 43,8%. A peritonite foi a infecção mais comum (24%), seguida por pneumonia (18%), infecção do trato urinário (15%) e celulite (14%), contribuindo com dois terços das principais infecções. Streptococcus pneumoniae (n = 9) foi o organismo predominantemente isolado em crianças com peritonite e pneumonia. Na análise de regressão logística, a albumina sérica < 1,5gm / dL foi o único fator de risco independente para todas as infecções (OR 2,6; 95% CI, 1,2-6; p = 0,01), especialmente para peritonite (OR 29; IC95% 3 -270, p = 0,003). Houve quatro mortes (2,5%) em nosso estudo, todas devido a sepse e falência de múltiplos órgãos. Conclusões: A infecção continua sendo uma importante causa de morbimortalidade em crianças com síndrome nefrótica. Como o Pneumococo foi a causa mais prevalente de infecção nessas crianças, deve-se atentar para a imunização pneumocócica em crianças com síndrome nefrótica.

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.