Effect of prednisolone on linear growth in children with nephrotic syndrome / Efeito da prednisolona sobre o crescimento linear em crianças com síndromenefrótica

Abstract Objective This study aims at determining the relationship between prednisolone cumulative dose and linear growth in pre-pubertal children with idiopathic nephrotic syndrome. Method This cross-sectional study was conducted on all children with idiopathic nephrotic syndrome registered to the pediatric nephrology department at the main referral children's hospital in Southwestern Iran. Inclusion criteria included age (males <12 years; females <10 years), >6 months of use, and the minimum prednisolone cumulative dose of 152 mg/kg. The exclusion criteria were individuals who had entered puberty or had other diseases affecting linear growth. Based on the prednisolone cumulative dose of ≥550 mg/kg (four or more relapses), the children were divided into two groups. All data regarding age, height, and weight at disease onset and the last visit, bone age, and the parents' height were collected. Secondary variables including mid-parental target height and predicted adult height were also calculated. Height data were compared between the different rates of relapse. Results A total of 97 children (68% male) were enrolled. Their post-treatment mean height Z-score was less than that obtained before treatment (−0.584 vs. −0.158; p = 0.001). Subjects with higher prednisolone cumulative doses were found to have more reduction in height Z-score (p = 0.001). Post-treatment height prediction also showed less growth potential compared to pre-treatment target height (p = 0.006). Thirty-three children (34.4%) had four or more relapses, among whom more mean-height Z-score decreases were found compared to those with less-frequent relapses (−0.84 vs. −0.28; p = 0.04). Conclusion This study showed the negative effect of cumulative dosages of prednisolone on linear growth, which was greater in children with four or more relapses.

Resumo Objetivo Determinar a relação entre a dose cumulativa de prednisolona e o crescimento linear em crianças pré-púberes com síndrome nefrótica idiopática. Método Estudo transversal conduzido em todas as crianças com síndrome nefrótica idiopática registradas no departamento de nefrologia pediátrica no principal hospital infantil para encaminhamento no sudoeste do Irã. Os critérios de inclusão incluíram idade (meninos < 12 anos; meninas < 10 anos), > 6 meses e a dose cumulativa de prednisolona mínima de 152 mg/kg. Os critérios de exclusão foram indivíduos que entraram na puberdade ou tinham outras doenças que afetam o crescimento linear. Com base na dose cumulativa de prednisolona de ≥ 550 mg/kg (≥ 4 recidivas), as crianças foram divididas em dois grupos. Foram coletados todos os dados relacionados a idade, estatura e peso no início da doença e na última visita, idade óssea e estatura dos pais. Também foram calculadas as variáveis secundárias, inclusive estatura-alvo e estatura adulta prevista. Os dados de estatura foram comparados entre as diferentes taxas de recidivas. Resultados Foram inscritas 97 crianças (68% do sexo masculino). Seu escore z de estatura média pós-tratamento foi inferior ao obtido antes do tratamento (−0,584 em comparação com −0,158; p = 0,001). Os indivíduos com maiores doses cumulativas de prednisolona mostraram maior redução no escore z para estatura (p = 0,001). A estatura pós-tratamento também foi preditiva de menor potencial de crescimento em comparação com a estatura-alvo pré-tratamento (p = 0,006); 33 crianças (34,4%) apresentaram ≥ 4 recidivas, entre as quais foram encontradas mais reduções médias no escore z para estatura em comparação com as recidivas menos frequentes (−0,84 em comparação com −0,28; p = 0,04). Conclusão Este estudo mostrou o efeito negativo das doses cumulativas de prednisolona sobre o crescimento linear, que foi maior em crianças com ≥ 4 recidivas.

Platelet dysfunction among patients with end stage renal diseases [review article]

Introduction and Aims: Platelet dysfunction is a major determinant of bleeding among patients with end stage renal disease [ESRD], The present article has summarized some of published articles about clinical and laboratory manifestations, pathogenesis and treatment of platelet dysfunction among these patients

Materials and Methods: Collecting current data, many studies have reviewed with key words of platelet dysfunction, bleeding and ESRD in a variety of sources such as PubMed, Scopus, and etc. Manuscripts published in English and Persian languages as full-text articles were included in our study

Results: The causes of platelet impairment among patients with ESRD are multifactorial and include anemia, accumulation of uremic toxins, von willebrand factor dysfunction and increase synthesis of prosthacyclin and nitric oxide which are platelet inhibitor

Although specific therapy is not required in patients without bleeding, however correction of platelet dysfunction is desirable among patients with active bleeding or patients who candidate for kidney or liver biopsy. Treatment options include correction of anemia, dialysis, administration of desmopressin which increase release of VIII factor and von willebrand factor multimers from endothelial cells, cryoprecipitate and conjugated estrogens

Conclusion: Excessive bleeding may occur among uremic patients in response to injury or invasive and noninvasive procedures and therefore appropriate treatment should be performed among these patients

[ evaluation of dialysis adequacy by KTN in hemodialysis patients]

Patients with ESRD need adequate dialysis. According to DOQI guidelines, minimum dialysis dose by KT/V in patients under hemodialysis [HD] is 1.2 or greater. In a cross- sectional study, we evaluated the value of KT/V among HD patients in shahid Beheshti Hospital of Abadan, Iran. HD was performed for 3 to 4 hours, using synthetic dialyzer and the bicarbonate- based dialysate. Blood flow rate, dialysate flow rate and ultrafiltration rate were 250 to 300 cc /min, 500cc/min and zero or 1 to 3 liters, respectively. Blood sampling for BUN was done immediately before and after the dialysis session. We used the following equation to estimate the KT/V from the percent reduction in urea [PRU]. KT/V = [0.026 xPRU] - 0.460 54 HD patients [28 females and 26 males] with the mean age of 39 +/- 14.2 years were enrolled in the study. The most common cause of ESRD was hypertension [24.07%] followed by, unknown [22.22%], DM [18.51%], Chronic Glomerulonephritis [14.81%], urinary tract abstraction [12.96%] and poly cystic kidney disease [7.40%]. KT/V was less than 1.2 in 87.03 patients [n=47]. There was no significant difference in the valve of KT/V in men and women [P= 0.54] and in different hemoglobin concentration [p=0.58]. The results of the study show that the most of our HD patients have not received minimum dialysis dose and we should evaluate and correct its causes

[Comparison of temporary dialysis catheter and A-V fistula use at the time of starting chronic hemodialysis among end-stage renal diseases patients]

The preferred type of access for chronic hemodialysis [HD] is an Arterio-Venous [A-V] Fistula. However most of the ESRD patients does not have a mature fistula at the time of starting HD due to late referral to the nephrologists so the managing physicians have to use temporary catheters with high rate of complications. In a retrospective study we determined and compared the prevalence of temporary catheters or A-VFistula use at the time of starting chronic HD from November 1995 to June 2009. We have divided our patients in three different groups. Group A: HD patients between 1995-2005, Group B: HD patients between 2006-2007, and Group C: HD patients after 2007. A total of 473 ESRD patients [288 male, 185 female; mean age, 55.8 +/- 16.4 years] were included in the study. Causes of ESRD were HTN 34.1%, DM 20. 08%, glomeronephritis 9.72%, obstructive uropathy 8.46%, ADPKD 5.92%, and unknown 21.77%. Overall the prevalence of temporary catheters and A-V Fistula use were 86.5 and 13.5 percent. But the prevalence was different in the studied groups: group A [93.6% and 6.4%], in group B [85.0% and 15.0%] and in group C [67.5% and 29. 5%] respectively. There was a significant increase in A-V Fistula use after 2005 [p=0.00] and especially after 2007 [p=0.000]. Although there was a significant increment in the A-V Fistula use, it is not still enough and general physicians, nurses and chronic kidney disease patients have to be educated about the benefits of early A-V Fistula creation

[Epidemiology of chronic kidney disease in Iran and worldwide]

Chronic kidney disease [CKD] is a worldwide public health problem. Increasing evidence indicates that earlier stages of CKD can be detected through laboratory testing, and that therapeutic interventions implemented early in the course of CKD are effective in slowing or preventing the progression toward end stage renal failure and its associated complications. Each physician should consider how he/she can contribute to an increase in the local screening, identification, and treatment efforts for CKD. Multidisciplinary collaboration between physicians, health care workers, and the government is necessary to halt the progression of CKD. Unfortunately, there is paucity of data concerning epidemiologic characteristics of CKD in Iran, resulting in lost opportunities for prevention. The present article summarizes recent observations about CKD epidemiology, both in Iran and worldwide

Survival at 1, 3, and 5 years in diabetic and nondiabetic patients on hemodialysis

We analyzed survival of 185 adult patients on maintenance hemodialysis [9 h/wk to 12 h/wk] at Emam Khomini Hospital in Ahvaz, Iran. Patient survival at 1, 3, and 5 years was 89.2%, 69.2%, and 46.8%, respectively. There was no significant difference between diabetic and nondiabetic patients in 1-year survival [87.1% versus 89.7%, P = .66]. But, 3- and 5-year survival rates of diabetic patients were significantly lower than those of nondiabetic patients [52.2% versus 73.8%, P = .04; zero versus 56.9%, P < .001; respectively]. Based on our findings, the survival of diabetic patients undergoing hemodialysis was much worse than survival of nondiabetic patients. Thus, prevention of diabetic nephropathy should be more emphasized; and if end-stage renal disease is present, other renal replacement therapies such as kidney transplantation must be considered as soon as possible

Evaluation of acquired cystic kidney disease in patients on hemodialysis with ultrasonography

Acquired cystic kidney disease [ACKD] occurs in patients with prolonged uremia, and early detection is important, because clinically significant complications, especially renal cell carcinoma, are associated with ACKD. In a cross-sectional study, we evaluated our patients on hemodialysis, in Ahvaz, Iran, using ultrasonography. The criteria for the diagnosis of ACKD were the presence of at least 4 bilateral renal cysts in patients with noncystic primary kidney diseases as the leading cause of kidney failure. A total of 148 patients [95 men and 53 women] were included in the study. The prevalence of ACKD was 20.3% [18.9% in men and 22.6% in women]. The mean age in patients with and without ACKD was 60.6 +/- 16.8 years and 53.6 +/- 14.9 years, and the mean hemodialysis duration was 44.2 +/- 18.7 months and 34.3 +/- 23.5 months, respectively. There were no significant differences in the frequency of ACKD in the men and the women [P = .59] and in the etiology of end-stage renal disease [P = .64]. It was significantly more likely to see ACKD in patients with a history of 3 years or longer being on hemodialysis than in those with a shorter dialysis duration [P = .001]. Acquired cystic kidney disease is common in patients on hemodialysis, and we suggest that renal ultrasonography be performed in patients with 3 years or more history of being on renal replacement therapy