Enfoque médico social de la enfermedad renal crónica en Pediatría / Medical and social approach to chronic kidney disease in Paediatrics

RESUMEN Introducción: las malformaciones congénitas renales y de las vías urinarias constituyen un grupo heterogéneo de anomalías secundarias a un proceso anormal en el desarrollo embrionario del sistema renal. Objetivo: profundizar en los aspectos relacionados con el diagnóstico precoz de las malformaciones congénitas renales y de vías urinarias, como causa frecuente de la enfermedad renal crónica oculta en la edad pediátrica, desde una perspectiva integral y personalizada, sobre la base de un enfoque médico social. Métodos: se realizó una revisión sistemática sobre el tema en las bases de datos: EBSCO, SciELO, Scopus, PubMed, y en revistas de Nefrología pediátrica, de Pediatría, de Genética y de Teratología. Los artículos fueron publicados en idioma español o inglés. Se realizó un análisis de contenido directo para lograr la actualización teórica del tema con un enfoque médico social. Conclusiones: el desarrollo de la Nefrología pediátrica constituye una línea de trabajo del MINSAP. Sus principios son: la intersectorialidad, la prevención y la participación de especialidades afines (de manera que se alcancen resultados asistenciales, docentes e investigativos que determinen mayor calidad en el diagnóstico precoz de las malformaciones congénitas renales y de vías urinarias). Dicha afección es causa frecuente de la enfermedad renal crónica oculta en la edad pediátrica, desde una perspectiva integral y personalizada, sobre la base de un enfoque médico social.

ABSTRACT Introduction: congenital renal and urinary tract malformations constitute a heterogeneous group of anomalies secondary to an abnormal embryonic development of the renal system. Objective: to study in depth the aspects related to the early diagnosis of congenital renal and urinary tract malformations, as a frequent cause of occult chronic kidney disease in the paediatric age group, from an integral and personalized perspective, based on a medical and social approach. Methods: a systematic review on the subject was carried out in the following databases: EBSCO, SciELO, Scopus, PubMed, and in journals of Paediatric Nephrology, Paediatrics, Genetics and Teratology. The articles were published in Spanish or English languages. A direct content analysis was performed to achieve the theoretical update of the topic with a medical and social approach. Conclusions: the development of Paediatric Nephrology constitutes a line of work of MINSAP. Its principles are intersectoriality, prevention and participation of related specialities (in order to achieve care, teaching and research results that determine greater quality in the early diagnosis of congenital renal and urinary tract malformations). This condition is a frequent cause of occult chronic kidney disease in the paediatric age group, from an integral and personalized perspective, based on a medical and social approach.

Unilateral non-rotated left kidney with vascular and ureter variations in a cadaver: a unique case report with embryological and educational aspects / Rim esquerdo unilateral sem rotação com variações vasculares e de ureter em cadáver: relato de caso com aspectos embriológicos e educacionais

Abstract The kidneys and ureters are retroperitoneal structures in the upper part of the paravertebral gutters, tilted against the structures on the sides of the lowest two thoracic and upper three lumbar vertebrae, so that their anterior and posterior surfaces face antero-laterally and postero-medially, respectively. Congenital anomalies of the urinary tract are often the underlying cause of renal pathologies; 40% of these pathological conditions are due to variations in location, shape, and size of the kidney(s), calyces, ureter, or bladder. This case report describes the presence of a unilateral non-rotated left kidney with vascular and ureter variations found during routine cadaveric dissection for medical graduates. Alterations in rotation of the kidney and its relation to structures at the hilum have great clinical significance when conducting surgical procedures like partial nephrectomy, nephron sparing surgery, and renal transplantation.

Resumo Os rins e o ureter são estruturas retroperitoneais localizadas na parte superior do sulco paravertebral, inclinados contra as estruturas laterais das duas vértebras torácicas inferiores e das três vértebras lombares superiores. Assim, as superfícies anteriores e posteriores estão nas porções anterolateral e posteromedial, respectivamente. As anomalias congênitas do trato urinário frequentemente são causas subjacentes de patologias renais, e 40% delas ocorrem devido a variações no local, formato e tamanho dos rins, cálices, ureter ou bexiga. Este relato de caso descreve a presença de rim esquerdo unilateral sem rotação com variações vasculares e de ureter encontradas durante uma dissecção de cadáver rotineira com graduandos de Medicina. As alterações na rotação do rim e a sua relação com as estruturas no hilo têm grande importância clínica durante procedimentos cirúrgicos como a nefrectomia parcial, a cirurgia poupadora de néfrons e o transplante renal.

Factores asociados a malformaciones congénitas renales y de vías urinarias / Factors associated to renal and urinary tract ´s congenital malformations

Introducción: Las malformaciones congénitas del riñón y del tracto urinario representan entre 20 y 30 por ciento de todas las malformaciones reconocidas en humanos. Objetivo: Identificar los antecedentes patológicos familiares y las enfermedades durante el embarazo asociados a la aparición de defectos congénitos renales. Métodos: Estudio descriptivo prospectivo transversal realizado en 672 niños nacidos entre julio de 2014 y junio de 2015 en Santa Clara, con ultrasonido prenatal normal. A todos los niños durante la consulta médica se les hizo examen físico detallado y previo consentimiento informado del familiar acompañante, se aplicó a estos una encuesta y se registraron variables epidemiológicas, antecedentes familiares de enfermedades renales, morbilidad de la madre durante el embarazo y se realizó un ultrasonido renal para identificar las alteraciones sonográficas sugerentes de algún tipo de anomalías del desarrollo renal. Resultados: En 40 (5,95 por ciento) pacientes se detectó alteración sonográfica. El 27,50 por ciento eran hijos de madres que presentaron alguna enfermedad durante el embarazo. La glucemia elevada afectó 10 por ciento de las madres de los niños con anomalías del desarrollo renal, seguida del bajo peso materno (7,5 por ciento). El hecho de presentar antecedente patológico familiar de enfermedad renal aportó un riesgo de 1,88 y en las de tipo obstructivo el riesgo fue de 5,08. Conclusiones: Las alteraciones sonográficas sugestivas de malformación congénita renal son más frecuentes en los lactantes cuyas madres presentaron concentraciones elevadas de glucosa y bajo peso durante el embarazo. Los niños con antecedentes familiares de malformación renal tienen mayor riesgo de presentar una anomalía del desarrollo renal(AU)

Introduction: Kidney and urinary tract´s malformations represent among 20 and 30 percent of all malformations known in humans. Objective: To identify during pregnancy family pathological history and diseases associated to the onset of renal congenital malformations. Methods: Prospective, descriptive, cross-sectional study carried out to 672 children with normal prenatal ultrasound whom were born from July, 2014 to June 2015 in Santa Clara province. All children during the medical consultation had a detailed physical examination and previous informed concent; it was applied also a survey and the epidemiologic variables, family history of renal diseases, morbility of the mother during pregnancy were recorded, and it was made a renal ultrasound to identify sonographic alterations suggesting any kind of anomaly in the renal development. Results: In 40 patients (5,95 percent), it was detected any sonographic alteration. 27,50 percent were children of mothers that presented any disease during pregnancy. High glycemia affected the 10 percent of mothers of children with anomalies in the renal development, followed by low maternal weight (7,5 percent). The fact of presenting a family pathological history of renal disease implied a risk of 1,88 percent and the risk was of 5,08 percent in the obstructive kind of diseases. Conlusions: Sonographic alterations suggesting renal congenital malformations are more frequent in newborns whose mothers had high concentrations of glycemia and low weight during pregnancy. Children with family history of renal malformations have higher risk of presenting an anomaly of the renal development(AU)

Diagnóstico prenatal y posnatal de anomalías del tracto urinario / Pre- natal and post-natal diagnosis of urinary tract anomalies

Introducción: El ultrasonido prenatal aporta una magnífica forma de introducirnos en la patofisiología renal humana, pero es incapaz de detectar todas las anomalías. Objetivos: Identificar las principales anomalías de riñón y tracto urinario en pacientes con diagnóstico prenatal o posnatal de estas anomalías. Métodos: Se incluyeron en el estudio todos los pacientes que llegaron remitidos al servicio de Nefrología del Hospital Pediátrico Docente William Soler entre el 1ero. de octubre de 2015 y el 30 de septiembre de 2017, por haberse detectado alteraciones en el ultrasonido prenatal durante el seguimiento de un embarazo normal y aquellos en los que después del nacimiento se comprobó alguna anormalidad en forma incidental o por síntomas relacionados. Se programó seguimiento clínico, imagenológico y terapéutico de acuerdo con la anomalía detectada. Resultados: El estudio incluyó 81 pacientes, 65 con diagnóstico prenatal y 16 con hallazgo posnatal. El sexo masculino estuvo representado por el 66,7 por ciento y la anomalía más frecuente estudiada resultó la displasia renal multiquística (23,4 por ciento). En segundo lugar, el diagnóstico morfológico correspondió a dilataciones del tracto urinario, que en su estudio posnatal se clasificaron como hidronefrosis (20,9 por ciento), pielectasias (17,4 por ciento) y reflujo vesicoureteral (7,4 por ciento). Conclusiones: El ultrasonido prenatal para la detección de anomalías de riñón y tracto urinario es un proceder diagnóstico de gran utilidad porque permite prepararnos para enfrentar estas anomalías antes que presente síntomas relacionados y además puede proporcionar una adecuada información a los padres. No todas las anomalías congénitas se detectan mediante ecografía prenatal(AU)

Introduction: The prenatal ultrasound provides a great way to introduce us to the human renal pathophysiology, but is unable to detect all of the anomalies. Objectives: To identify the main anomalies of the kidney and urinary tract in patients with prenatal or postnatal diagnosis of those. Methods: There were included in the study all the patients who were referred to the Nephrology Service of William Soler Pediatric Teaching Hospital from October 1, 2015 to September 30, 2017 being detected alterations in the prenatal ultrasound during the follow-up of a normal pregnancy and those in which after birth any abnormality was found incidentally or by related symptoms. Clinical, imaging and therapeutic follow-up were scheduled in accordance with the anomaly detected. Results: The study included 81 patients, 65 with prenatal diagnosis and 16 with post-natal finding. The male sex was represented by the 66.7 percent and the most common anomaly studied was the multicystic dysplastic kidney (23.4 percent). Secondly, the morphological diagnosis corresponded to dilations of the urinary tract, which in the post-natal study were classified as hydronephrosis (20.9 percent), pyelectasis (17.4 percent) and vesicoureteral reflux (7.4 percent). Conclusions: The prenatal ultrasound for the detection of kidney and urinary tract´s anomalies is a diagnosis of great utility because it allows us to prepare to face these anomalies before they present related symptoms and it can also provide adequate information to parents. Not all congenital anomalies are detected by prenatal ultrasound(AU)

Características clínicas y evolución del reflujo vesicoureteral en la infancia / Clinical characteristics and outcome of childhood vesicoureteral reflux

Introducción. El objetivo fue evaluar las características clínicas y la evolución del reflujo vesicoureteral (RVU) según el sexo y grado de RVU.Población y métodos. Se incluyeron pacientes con RVU vistos durante el seguimiento de rutina entre enero de 2014 y enero de 2015. Se registraron las características demográficas, la evolución, los laboratorios y las imágenes.Resultados. Se seleccionó a 220 pacientes, cuya media de edad del diagnóstico era 3,17 ± 3,08 años; en ese momento, los varones eran menores que las niñas (2,00 ± 2,59 vs. 3,81 ± 3,15, p < 0,001). La infección urinaria fue la presentación más frecuente, seguida de hidronefrosis prenatal (HNP). El 22 % de los pacientes tuvo reflujo de grado 1-2; el 51 %, de grado 3; y el 27 %, de grado 4-5. En el reflujo de grado 4-5, las ecografías y gammagrafías con ácido dimercaptosuccínico (DMSA) marcado con 99mTc presentaron más anomalías, y se realizaron más cirugías (p < 0,001). En los varones, fueron más comunes el reflujo de grado 4-5 (43,6 % vs. 18,3 %) y las anomalías ecográficas (77 % vs. 54 %) y en la DMSA (77 % vs. 59 %) (p < 0,05). En las niñas, hubo mayores tasas de infección urinaria, disfunción de las vías urinarias inferiores y resolución espontánea (p < 0,05).Conclusiones. A pesar de la menor edad al momento del diagnóstico, la resolución espontánea fue menor en los varones, y estos presentaron HNP, reflujo grave y anomalías radiológicas más frecuentemente.

Introduction. The aim of the study was to assess the clinical features and outcome parameters of children with vesicoureteral reflux (VUR) based on gender and VUR grade.Population and methods. Patients with VUR who were seen during routine follow-up visits at Ankara University Children's Hospital between January 2014-January 2015 were included in this retrospective study. Patient demographics, clinical course, laboratory investigations, imaging were noted.Results. Two hundred and twenty patients were recruited. Mean age at the time of diagnosis was 3,17 ± 3,08 years. Boys were diagnosed at younger ages as compared to girls (2.00 ± 2,59 vs. 3,81 ± 3.15, p < 0.001). Urinary tract infection (UTI) was the most common presentation. The second presentation form was antenatal hydronephrosis (AHN) which was more common in males (25.6 %, p < 0.001). Twenty-two percent of the patients had grade 1-2, 51 % grade 3 and 27 % grade 4-5 reflux. Patients with grade 4-5 reflux had more abnormal ultrasound (US) and Tech 99m dimercaptosuccinic acid scintigraphy (DMSA) findings and surgery was performed more frequently in this group (p < 0.001). In males, grade 4-5 reflux (43.6 % vs. 18.3 %), abnormal US (77 % vs. 54 %) and DMSA (77 % vs. 59 %) findings were more frequent (p < 0.05). In girls higher rates of UTIs, lower urinary tract dysfunction (LUTD) and spontaneous reflux resolution were seen (p < 0.05).Conclusions: Despite younger age at diagnosis, spontaneous resolution was found lower in boys and they had more frequent AHN, more severe reflux, and radiological abnormalities.

Transperitoneal laparoscopic pyeloplasty in children: does upper urinary tract anomalies affect surgical outcomes?

ABSTRACT Objective To assess the feasibility and outcomes of laparoscopic pyeloplasty in children with complex ureteropelvic junction obstruction (UPJO) and compare to children with iso-lated UPJO without associated urinary tract abnormalities. Material and Methods Medical records of 82 consecutive children submitted to transperi-toneal laparoscopic pyeloplasty in a 12-year period were reviewed. Eleven cases were con-sidered complex, consisting of atypical anatomy including horseshoe kidneys in 6 patients, pelvic kidneys in 3 patients, and a duplex collecting system in 2 patients. Patients were di-vided into 2 groups: normal anatomy (group 1) and complex cases (group 2). Demographics, perioperative data, outcomes and complications were recorded and analyzed. Results Mean age was 8.9 years (0.5-17.9) for group 1 and 5.9 years (0.5-17.2) for group 2, p=0.08. The median operative time was 200 minutes (180-230) for group 1 and 203 minutes (120-300) for group 2, p=0.15. Major complications (Clavien ≥3) were 4 (5.6%) in group 1 and 1 (6.3%) in group 2, p=0.52. No deaths or early postoperative complications such as: urinoma or urinary leakage or bleeding, occurred. The success rate for radiologic improvement and flank pain improvement was comparable between the two groups. Re-garding hydronephrosis, significant improvement was present in 62 patients (93.4%) of group 1 and 10 cases (90.9%) of group 2, p=0.99. The median hospital stay was 4 days (IQR 3-4) for group 1 and 4.8 days (IQR 3-6) for group 2, p=0.27. Conclusions Transperitoneal laparoscopic pyeloplasty is feasible and effective for the management of UPJO associated with renal or urinary tract anomalies.

Malformaciones renales y del tracto urinario con daño renal en Pediatría / Renal and urinary tract malformations with renal damage in pediatrics

INTRODUCTION: renal and/or urinary pathway malformations are the frequent cause of chronic renal disease at pediatric ages worldwide. OBJECTIVE: to describe the alteration of the renal functioning in these patients, by age, at the time of diagnosis of renal and urinary pathway malformations. METHODS: a cross-sectional descriptive study of patients diagnosed with renal and urinary duct malformations was made in Villa Clara province from January 2012 through December 2013. RESULTS: forty patients were diagnosed at prenatal phase, 75 % of them were males; 85 were diagnosed after birth and 38 of them after one year of age, 60 % were girls. One hundred and twenty five renal units had reflux and 60 % of them located on the left kidney. It was observed that left kidney malformations prevailed, with 57 patients (45.6 %), but in 28 of patients, the renal damage was bilateral. CONCLUSIONS: vesicoureteral reflux, mainly on the left one, was the most diagnosed malformation; postnatal diagnosis predominated and although there was no difference in terms of sex, males prevailed in patients with prenatal diagnosis and females were the most diagnosed after birth. The left kidney was more frequently affected, but the renal damage was detected more often in bilateral condition.

INTRODUCCIÓN: las malformaciones renales y/o de vías urinarias constituyen una causa frecuente de enfermedad renal crónica en la edad pediátrica a nivel mundial. OBJETIVO: describir la afectación del funcionamiento renal que tenían estos pacientes, según la edad, al diagnóstico de las malformaciones renales y de vías urinarias. MÉTODOS: se realizó un estudio descriptivo, de corte transversal en Villa Clara, con pacientes con diagnóstico de malformaciones renales y de vías urinarias en el período comprendido desde enero de 2012 a diciembre de 2013. RESULTADOS: se diagnosticaron 40 pacientes en etapa prenatal, de ellos 75 % eran del sexo masculino, 85 después del nacimiento y de ellos 38 posterior al año de vida, el 60 % eran niñas; 125 unidades renales tenían reflujo, de los cuales el 60 % correspondía al izquierdo. Se apreció un predominio de las malformaciones en el riñón izquierdo, con 57 pacientes (45,6 %), pero 28 de los enfermos con daño renal tenían afectación bilateral. CONCLUSIONES: el reflujo vesicoureteral, fundamentalmente el izquierdo, fue la malformación más diagnosticada; predominó el diagnóstico posnatal, y aunque de manera general no hubo diferencia en cuanto al sexo, fue más frecuente el masculino en los pacientes con diagnóstico prenatal, y el femenino en los que se realizó el diagnóstico tras el nacimiento. El riñón izquierdo se afectó con mayor frecuencia, pero el daño renal fue más frecuente cuando la afectación fue bilateral.

Enfoque diagnóstico de la hematuria en pediatría / Diagnostic approach to a child with hematuria

La hematuria es un hallazgo clínico observado por el paciente o un familiar cuando es macroscópica o bien incidental en un parcial de orina rutinario. La prevalencia es baja pero el enfoque diagnóstico al cual está enfrentado el clínico es amplio. La hematuria indica enfermedad, lesión o malformación del tracto urinario, por ello el médico general y el pediatra deben estar en capacidad de determinar a tiempo algunas de las causas con pronóstico grave o diagnóstico complejo que requieren la remisión al nefrólogo pediatra. Se hace énfasis en diferenciar si es o no de origen glomerular, adoptando un algoritmo de enfoque diagnóstico que orienta al clínico. Se realizó una búsqueda limitada de 2001-2014 en las principales bases de datos en inglés y español encontrando revisiones de la literatura, consensos de expertos y guías de práctica clínica basadas en la opinión de pediatras, nefrólogos y urólogos pediatras, así como de radiólogos que ofrecen una aproximación real a la imagenología. Está dirigida a personal de la salud, médicos generales y pediatras quienes enfrentan a diario esta condición clínica.

Hematuria is a clinical finding observed by the patient or a relative if it is macroscopic, or is an incidental finding in a routine urinalysis. Prevalence rate is low but the range of differential diagnoses faced by the physician is broad. Hematuria indicates disease, lesion or malformation of the urinary tract, thus the general practitioner and the pediatrician must be capable to determine the etiologies that have a poor prognosis or are difficult to diagnose which require prompt referral to a pediatric nephrologist. We emphasize on the development of a diagnostic algorithm to help the physician distinguish glomerular from non-glomerular hematuria. A limited search from 2001-2014 was conducted in the major data bases in English and Spanish finding literature reviews, expert consensus and clinical practice guidelines based on the opinion of pediatricians, and pediatric nephrologists and urologists, as well as radiologists who offer a real approach to imaging. It is oriented toward health care providers, general practitioners and pediatricians who face this clinical condition in their daily practice...

Infección urinaria en pediatría / Urinary tract infection in children

La infección de las vías urinarias es una patología frecuente en la edad infantil, por lo que el médico general, el pediatra y los involucrados en el diagnóstico y manejo del niño afectado están en la obligación de conocer las actualizaciones sobre el mecanismo fisiopatológico, métodos diagnósticos y tratamientos actuales. Se hace énfasis en la prevención, el uso racional de antibioticoterapia y los nuevos enfoques terapéuticos que se pueden ofrecer...

Urinary tract infection (UTI) is a common illness in children, thus the general practitioner, the pediatrician and those involved in the diagnosis and management of the affected child must keep updated on UTI physiopathology, diagnostic methods and current treatments. We emphasize on prevention, rational use of antibiotic therapy and new therapeutic approaches available...

Chronic kidney disease among children in Guatemala / Enfermedad renal crónica en niños de Guatemala

OBJECTIVE: To describe the distribution of pediatric chronic kidney disease (CKD) in Guatemala, estimate incidence and prevalence of pediatric end-stage renal disease (ESRD), and estimate time to progress to ESRD. METHODS: This study analyzed the registry of the only pediatric nephrology center in Guatemala, from 2004-2013. Incidence and prevalence were calculated for annual periods. Moran's index for spatial autocorrelation was used to determine significance of geographic distribution of incidence. Time to progress to ESRD and associated risk factors were calculated with multivariate Cox regression. RESULTS: Of 1 545 patients from birth to less than 20 years of age, 432 had chronic renal failure (CRF). Prevalence and incidence of ESRD were 4.9 and 4.6 per million age-related population, respectively. Incidence was higher for the Pacific coast and Guatemala City. The cause of CRF was undetermined in 43% of patients. Average time to progress to ESRD was 21.9 months; factors associated with progression were: older age, diagnosis of glomerulopathies, and advanced-stage CKD at consultation. CONCLUSIONS: Prevalence and incidence of ESRD in Guatemala are lower than in other countries. This may reflect poor access to diagnosis. Areas with higher incidence and large proportion of CKD of undetermined cause are compatible with other studies from the geographic subregion. Findings on progression to ESRD may reflect delayed referral.

OBJETIVO: Describir la distribución de enfermedad renal crónica en niños en Guatemala, y calcular la incidencia y la prevalencia de nefropatía terminal en niños, así como el tiempo de progresión hasta la nefropatía terminal. MÉTODOS: Este estudio analizó el registro del único centro de nefrología pediátrica de Guatemala, del 2004 al 2013. La incidencia y la prevalencia se calcularon por períodos anuales. Se utilizó el índice de Moran como medida de la autocorrelación espacial con objeto de determinar la significación de la distribución geográfica de la incidencia. El tiempo de progresión a la nefropatía terminal, así como los factores de riesgo asociados, se calcularon mediante la regresión de Cox de variables múltiples. RESULTADOS: De 1 545 pacientes menores de 20 años, 432 padecían insuficiencia renal crónica. La prevalencia y la incidencia de nefropatía terminal fueron de 4,9 y 4,6 por millón de habitantes de esa misma edad, respectivamente. La incidencia fue mayor en la costa del Pacífico y en la Ciudad de Guatemala. En 43% de los pacientes la causa de la insuficiencia renal crónica era indeterminada. El tiempo promedio de progresión a una nefropatía terminal fue de 21,9 meses; los factores asociados con esa progresión fueron: la edad mayor, el diagnóstico de glomerulopatía y la enfermedad renal crónica en etapa avanzada en el momento de la consulta. CONCLUSIONES: La prevalencia y la incidencia de la nefropatía terminal en Guatemala son inferiores a las de otros países. Ello podría reflejar un acceso limitado al diagnóstico. La mayor incidencia y la amplia proporción de enfermedad renal crónica de causa indeterminada en algunas zonas son compatibles con las de otros estudios de la subregión geográfica. Los resultados en cuanto a progresión a una nefropatía terminal podrían ser el reflejo de la tardanza en la derivación.

Prevalencia de infección urinaria, uropatógenos y perfil de susceptibilidad antimicrobiana / Prevalence of urinary infection, uropathogens and antimicrobial susceptibility profile

Introducción: las infecciones del tracto urinario (ITU), constituyen una de las infecciones bacterianas más prevalentes, sus agentes etiológicos incluyen Escherichia coli, Klebsiella spp, Proteus spp, Enterococcus spp, Pseudomonas spp y Staphylococcus spp, los cuales presentan prevalenciasy perfiles de susceptibilidad antibiótica diferentes entre poblaciones. Objetivo: determinar la prevalencia de ITU, uropatógenos y el perfil de susceptibilidad antimicrobiana en una institución prestadora de servicios de salud (IPS) de Medellín, 2011-2012. Métodos: estudio de prevalencia en 1959 individuos atendidos en una IPS de tercer nivel. Se calcularon medidas de resumen, proporciones, razones de prevalencia, Chi cuadrado y Fisher. Se cuantificó la modificación del efecto (confusión o interacción) con análisis estratificado y modelos de regresión logística binaria en SPSS 21.0®. Resultados: la prevalencia de ITU fue 31%; los principales agentes etiológicos fueron E. coli (69%), Enterococcus spp (11%) y Klebsiella spp (8%). La ITU y la infección por E. coli fueron estadísticamente mayores en mujeres y adultos mayores. La mayor frecuencia de resistencia de E. coli fue para ampicilina (61%), ácido nalidixico (48%), trimetoprim sulfametoxazol (48%) y ciprofloxacina (42%); mientras que en Klebsiella spp fue trimetoprim sulfametoxazol (23%), ampicilina-sulbactam (22%) y cefalotina (19%). Conclusión: la elevada prevalencia de ITU, la multiplicidad de uropatógenos aislados, la identificación de grupos de mayor riesgo y la diversidad de perfiles de resistencia antibiótica, evidencian la necesidad de desarrollar investigaciones locales que permitan orientar las acciones en salud y vigilancia epidemiológica, acordes con las particularidades de cada población.

Introduction: urinary tract infections (UTI) are one of the most prevalent bacterial infections; its etiological agents include Escherichia coli, Klebsiella spp, Proteus spp, Enterococcus spp, Pseudomonas spp and Staphylococcus spp, which have different prevalence and antibiotic susceptibility profiles among populations. Objective: to determine the prevalence of UTI, uropathogens and antimicrobial susceptibility profile in an Institution of Health Services of Medellin, 2011-2012. Methods: prevalence study in 1959 patients seen in a tertiary health institution. Summary measures, ratios, prevalence ratios, chi-square and Fisher were calculated. Effect modification (confusion or interaction) with stratified analysis and models in binary logistic regression models in 21.0® was quantified. Results: the prevalence of UTI was 31%; the main etiological agents were E. coli 69%, Enterococcus spp 11% and Klebsiella spp 8%. UTI and E. coli infection were statistically higher in women and older adults. The higher frequency of E. coli resistance was 61% for ampicilin, 48% for nalidixic acid, 48% for trimethoprim-sulfamethoxazole and 42% for ciprofloxacin, while for klebsiella spp was 23% for trimethoprim-sulfamethoxazole, 22% for ampicillin-sulbactam and 19% for cephalothin. Conclusion: the high prevalence of UTI, the multiplicity of isolated uropathogens, identificationof high risk groups and diversity of antibiotic resistance profiles, show the need to develop local research to guide actions in health and epidemiological surveillance according to the particularities of each population.

Evolución de niños con anomalías del tracto urinario y propuesta de interrupción del embarazo / Progress of children with urinary tract anomalies and proposal of pregnancy cessation

Introducción: el ultrasonido diagnóstico prenatal realizado en los embarazos normales ha demostrado que por cada 500 embarazos debe aparecer una anomalía importante del tracto urinario. En diferentes situaciones puede sugerirse o recomendarse la interrupción del embarazo, que puede ser aceptado o rechazado por los padres. Objetivos: comparar el diagnóstico pre y posnatal, y valorar la evolución en 8 pacientes en los que se propuso la interrupción, pero el embarazo continuó. Resultados: en 6 de los fetos se propuso la interrupción por el diagnóstico de hidronefrosis bilateral; en uno, por quistes renales bilaterales, y en otro por hidronefrosis unilateral y displasia renal multiquística contralateral. En 2 recién nacidos hubo coincidencia total entre el diagnóstico prenatal y el posnatal, en uno con reflujo de alto grado se encontró ureterohidronefrosis bilateral en el estudio prenatal, mientras que en 2 solamente hidronefrosis; un paciente tiene megauréter bilateral no obstructivo, y otro pielectasia bilateral. En el feto que se plantearon los quistes renales bilaterales, el estudio posnatal mostró un doble sistema excretor derecho con el superior obstruido, y reflujo vesicoureteral grado III del inferior con riñón izquierdo normal. Durante el tiempo de seguimiento la conducta médica varió de acuerdo con el diagnóstico posnatal. Al concluir el período de seguimiento, un paciente tiene una enfermedad renal crónica etapa 3, y los 7 restantes tienen función renal conservada. Conclusiones: la indicación de interrupción del embarazo por el diagnóstico ultrasonográfico prenatal de una anomalía renal o de tracto urinario tiene un margen de error que es necesario seguir estudiando y buscar indicadores de alto riesgo vital, porque los factores predictivos no están bien precisados

Introduction: prenatal ultrasound diagnosis performed in normal pregnancies has shown that one significant urinary tract anomaly occurs per 500 pregnancies. Under different circumstances, termination of pregnancy may be suggested or recommended, which may be accepted or rejected by parents. Objectives: to compare the pre-and postnatal diagnoses, and to assess the progress in 8 patients who were recommended to terminate their pregnancies, but they rejected this idea. Results: in 6 cases, the termination of pregnancy was suggested on account of bilateral hydronephrosis diagnosis in their fetuses; in one case due to bilateral renal cysts diagnosis and in the other case due to unilateral hydronephrosis and contralateral multicystic renal dysplasia. There was full agreement between the prenatal and postnatal diagnoses in 2 newborns; in a neonate with high grade reflux, the prenatal study revealed bilateral ureterohydronephrosis whereas this study showed just hydronephrosis for other two fetuses. One patient has non-obstructive bilateral megaureter and the other presents bilateral pyelectasy. The fetus with bilateral renal cysts presented, according to the postnatal study, a double right excretory system, being the upper obstructed and the lower with grade III vesicoureteral reflux, but his left kidney was normal. In the follow-up period, the medical behavior varied according to the postnatal diagnoses. Upon finishing this period, one patient had phase III chronic renal disease and the other seven had preserved renal function. Conclusions: the indication of termination of pregnancy based on the prenatal ultrasonographic diagnosis of a renal or urinary tract anomaly has an error index that must be further studied, and it is necessary to look for high life risk indicators because the predictive factors are not well detailed

Study of the association between the BMP4 gene and congenital anomalies of the kidney and urinary tract / Estudo da associação entre o gene BMP-4 e anomalias congênitas do rim e trato urinário

OBJECTIVE: To determine the frequency of different phenotypes for congenital anomalies of the kidney and urinary tract (CAKUT) in a Brazilian sample, and to evaluate the association between the CAKUT phenotypes and the BMP4 gene. METHODS: In this study, 457 Brazilian individuals were analyzed in an attempt to establish the association between the BMP4 gene and the CAKUT diagnosis. A case-control sample was genotyped for three BMP4 gene polymorphisms. RESULTS: Association data was established with CAKUT sample as a whole and with the three most important CAKUT phenotypes: multicystic dysplastic kidney disease (MDK), ureteropelvic junction obstruction (UPJO) and vesicoureteral reflux (VUR). When the sample was segregated in these three phenotypes, associations between the BMP4 gene were observed with UPJO and with MDK. Conversely, VUR was not associated to the polymorphisms of the BMP4 gene. CONCLUSIONS: The present data suggest that Brazilian individuals with polymorphisms of the BMP4 gene have a higher risk to develop CAKUT, especially the malformations related to nephrogenesis and initial branching such as MDK and UPJO. Conversely, VUR appeared not to be related to BMP4 gene. .

OBJETIVO: Determinar a frequência de diferentes fenótipos de anomalias congênitas do rim e trato urinário (CAKUT) em uma amostra brasileira e avaliar a associação entre os CAKUT e o gene BMP-4. MÉTODOS: Neste estudo, analisamos 457 indivíduos brasileiros em uma tentativa de estabelecera associação entre o gene BMP-4 e o diagnóstico de CAKUT. As amostras de caso e de controle foram genotipadas em busca de três polimorfismos do gene BMP-4. RESULTADOS: Os dados de associação foram estabelecidos com a amostra de CAKUT como um todo e com os três fenótipos de CAKUT mais importantes: rim displásico multicístico (RDM), obstrução da junção ureteropélvica (UPJO) e refluxo vesico-ureteral (VUR). Quando a amostra foi separada nesses três fenótipos, encontramos associações entre o gene BMP-4 com UPJO e com RDM. Por outro lado, o VUR não foi associado aos polimorfismos do gene BMP-4. CONCLUSÕES: Esses dados sugerem que os indivíduos brasileiros com polimorfismos do gene BMP-4 apresentam maior risco de desenvolver CAKUT, principalmente as malformações relacionadas a nefrogênese e ramificação inicial, como RDM e UPJO. Por outro lado, o VUR parece não estar relacionado ao gene BMP-4. .

Antenatal diagnosis, prevalence and outcome of congenital anomalies of the kidney and urinary tract in Saudi Arabia

To study the prevalence, pattern of distribution, and the outcome of different types of kidney and urinary tract anomalies [CAKUT] diagnosed during the antenatal period. The second objective is to test the accuracy of antenatal diagnosis of CAKUT. In a cross-sectional hospital-based study, all cases diagnosed antenatally with urinary tract anomalies at King Abdulaziz University Hospital [KAUH], Jeddah, Kingdom of Saudi Arabia, were studied. The prevalence, pattern of distribution, and immediate postnatal outcomes, in addition to the accuracy of antenatal diagnosis, of those cases are reported. One hundred and forty-one cases of urinary tract anomalies were antenatally diagnosed; postnatal diagnosis was confirmed in 128 cases [90.1%]. The prevalence of CAKUT in our population is 3.26 per 1000 births. The most common abnormalities detected were hydronephrosis, polycystic kidney disease, multicystic dysplastic kidney, and renal agenesis, in descending order of frequency. The perinatal mortality rate among fetuses with CAKUT is 310 per 1000, the majority of these cases [90%] occurred in cases with renal parenchyma involvement. The prevalence of different types of CAKUT is higher than that reported in developed countries. Urinary tract anomalies can be accurately diagnosed and classified in the antenatal period using ultrasonography imaging. Antenatal diagnosis is a helpful tool in planning immediate postnatal care and deciding the place for delivery. This might prevent or slow renal function deterioration and help in early identification of patients who need early surgical intervention

Renal artery stenosis in association with congenital anomalies of the kidney and urinary tract

To describe 8 cases of renal artery stenosis [RAS] in children with congenital anomalies of the renal tract. We conducted a retrospective chart review of 78 children with RAS who were followed up at Great Ormond Street Hospital, London, United Kingdom between 2003 and 2012. We used an interventional radiology database to identify all patients who had RAS confirmed by digital subtraction angiography and examined all cases of congenital anomaly of the renal tract that had been diagnosed during childhood. We documented the following renal anomalies: multicystic dysplastic kidney [n=2], renal hypoplasia [n=1], congenital solitary kidney with hydronephrosis [n=1], and unilateral vesicoureteric reflux with poorly functioning kidneys [n=2]. The anomaly was unknown in 2 cases. Seven children had unilateral nephrectomy at a median age of 2.5 years [range, 0.4-10 years] for various urological abnormalities. All children were confirmed to have RAS after presentation with hypertension at a median age of 10 [3.5-16.2] years. Angioplasty was performed in 7 children, of which 6 achieved control of their blood pressure on reduced medications. We highlight the association between RAS and other renal anomalies, which indicates that they could share a common genetic background

Anomalías del tracto urinario y microorganismos diferentes a Escherichia coli en la infección urinaria neonatal / Anomalies of the urinary tract and microorganism other than Escherichia coli in the neonatal urinary infection

Objetivo: verificar si existe asociación entre tipo de microorganismo aislado en recién nacidos que inician una infección del tracto urinario y la presencia de anomalías del tracto urinario. Métodos: estudio observacional, prospectivo, desde 1992 hasta 2010, de una cohorte de 427 recién nacidos que ingresaron con la primera infección del tracto urinario, de localización alta, por criterios clínicos, y que se realizaron ultrasonido renal y uretrocistografía miccional. Se analizó la asociación entre la presencia de reflujo vésico-ureteral y otras anomalías del tracto urinario, con el tipo de microorganismo causal de la infección del tracto urinario. Resultados: los aislamientos bacterianos en los urocultivos correspondieron en 402 de los pacientes a microorganismos del género Enterobacteriaceae (94,1 por ciento), liderados por la E. coli en 276 (64,6 por ciento). La prevalencia de anomalías del tracto urinario resultó ser de 23,6 x 100. El problema más prevalente fue el reflujo vésico-ureteral, presente en 82 pacientes (19,2 x 100). Se comprobó que la presencia de reflujo vésico-ureteral tuvo asociación de riesgo estadísticamente significativa con el microorganismo causal diferente a E. coli (RR: 1,56; p< 0,05). De igual manera, se relacionó la presencia de reflujo vésico-ureteral o de otro tipo de anomalía del tracto urinario, con el microorganismo causal de la infección del tracto urinario, y los resultados del análisis fueron similares (RR:1,64; p< 0,01). Conclusiones: aunque la E. coli es el microorganismo causal más frecuente de la infección del tracto urinario neonatal, cuando se obtiene un aislamiento diferente a E. coli es muy probable que el paciente sea portador de una anomalía del tracto urinario, dado que la presencia de reflujo vésico-ureteral y otras anomalías del tracto urinario se asocian significativamente a aquellos diferentes a E. coli

Objective: to confirm whether the type of microorganism isolated in newborns with initial urinary tract infection and the anomalies of the urinary tract are associated or not. Methods: prospective and observational study of a cohort of 427 newborns, who were admitted to the hospital with their first urinary infection in the upper tract based on clinical criteria, and they underwent renal ultrasound and urethrocystography. The relationship between the vesicourethral reflux and other anomalies of the urinary tract with the type of causative microorganism of the urinary tract infection was analyzed. Results: bacterial isolates in uricultures were Enterobacteriaceae genus microorganisms in 402 patients (94.1 percent), led by E. coli in 276 (64.6 percent ). The prevalence of anomalies of the urinary tract was 23.6 x 100. The most prevalent problem was vesicourethral reflux found in 82 patients (19.2 x 100). It was confirmed that the presence of vesicourethral reflux had statistically significant association, in terms of risk, with causative microorganism other than E.coli (RR: 1.56; p< 0.05). Similarly, the presence of vesicourethral reflux or of other type of anomalies in the urinary tract was related to the causative microorganism of the urinary tract infection and the results of the analysis were similar (RR:1.64; p< 0.01). Conclusions: although E.coli is the most frequent causative microorganism of the neonatal urinary tract infection, when an isolate different from E. coli is obtained, it is very likely that the patient carries some anomaly of the urinary tract since the presence of the vesicourethral reflux and other anomalies of the urinary tract are significantly associated to microorganisms other than E.coli

Anomalias congênitas do trato urinário superior: novas imagens das mesmas doenças / Congenital upper urinary tract abnormalities: new images of the same diseases

Congenital upper urinary tract abnormalities imply a variable clinical spectrum of morphofunctional changes ranging from asymptomatic conditions to renal failure and incompatibility with life. Computed tomography, which has overcome excretory urography imaging, has been playing a key role in the diagnosis of congenital anomalies, serving as a better guidance in the therapeutic and surgical decision-making process, besides acting as an essential tool in the identification of associated complications and aiding in the performance of minimally invasive surgery techniques.

As anomalias congênitas do trato urinário superior implicam modificações morfofuncionais com espectro clínico variável, desde manifestações assintomáticas até falência renal e incompatibilidade com a vida. A tomografia computadorizada, além de ter superado o método de imagem da urografia excretora, tem desempenhado papel fundamental no diagnóstico das anomalias congênitas, orientando melhor nas decisões terapêuticas clínicas e cirúrgicas, além de atuar como ferramenta essencial na identificação de complicações associadas e no melhor desempenho de técnicas operatórias menos invasivas.