Plasma Neutrophil Gelatinase-Associated Lipocalin (2-0) Index: A Precise and Sensitive Predictor of Acute Kidney Injury in Children Undergoing Cardiopulmonary Bypass.

OBJECTIVE: To detect the efficacy of neutrophil gelatinase-associated lipocalin (NGAL) in the early prediction of acute kidney injury (AKI) in children undergoing cardiopulmonary bypass (CPB). METHODS: A prospective observational study was conducted wherein 174 patients, aged 6 to 60 months, with congenital heart disease, undergoing CPB and who had a normal baseline renal function were enrolled. Plasma NGAL measurement was done preoperatively and serially at 2, 12, 24, 36, and 48 hours post-CPB initiation. Patients were classified into 2 groups according to the development of postoperative AKI. RESULTS: Plasma NGAL levels post-CPB were significantly higher in the AKI group compared to the non-AKI group with positive significant correlations between plasma NGAL level and severity of AKI. A rise in plasma NGAL of 500% from its preoperative basal level, when measured at 2 hours post-CPB initiation (NGAL 2-0 index), showed sensitivity and specificity of 83% and 64%, respectively (AUC = 0.667) and at 12 hours post-CPB initiation (NGAL 12-0 index) showed sensitivity and specificity of 66% and 64% respectively (AUC = 0.762). CONCLUSION: Plasma NGAL is a predictive biomarker for acute kidney injury after pediatric cardiac surgery. A 500% rise in plasma NGAL at 2 hours post-CPB initiation from its basal preoperative level (NGAL 2-0 index) is a precise, sensitive, and early predictor of AKI in children.

A retrospective analysis of acute kidney injury in children with post-COVID-19 multisystem inflammatory syndrome: insights into promising outcomes.

BACKGROUND: Acute kidney injury (AKI) in patients with multisystem inflammatory syndrome (MIS), COVID-19 related infection has been increasingly recognized with a paucity of data on AKI incidence, related mortality, and the requirement of renal replacement therapy in children with MIS (MIS-C). METHODS: This is a retrospective study evaluating the prevalence, severity, management and outcomes of AKI in a cohort of Egyptian children with MIS-children (MIS-C) post-COVID infection. Patients were included if they met the criteria for MIS-C based on CDC guidelines. All patients were evaluated for AKI diagnosis and staging according to the Kidney Disease Improving Global Outcomes (KDIGO) criteria. RESULTS: Between March 2021 and June 2023, a total of 655 confirmed COVID-19 cases were admitted and then followed up in our hospital, of whom 138 (21%) were diagnosed with MIS-C. Fifty-one patients developed AKI associated with MIS-C post-COVID infection, 42 of whom were included in the analysis. Thirty-one patients had AKI in a formerly healthy kidney, of whom 51% (16 patients) were classified as KDIGO stage 3, 5 patients needed hemodialysis and 13 needed mechanical ventilation. Higher WBCs count, and serum ferritin on admission were associated with more severe AKI (KDIGO stage 3) (p = 0.04), while multivariate analysis showed high serum ferritin to be independent predictor of more severe AKI (p = 0.02). Two patients (2/31) died during hospital admission, while no residual renal impairment was reported at the time of discharge of patients with previously normal kidney functions. CONCLUSION: More than one-third of patients with MIS-C develop AKI. Avoidance of nephrotoxic drugs, early recognition, and prompt management of AKI, including well-timed commencement of dialysis in MIS-C cases, is associated with favorable outcomes.

Inferior Vena Cava Collapsibility Index: A Precise, Noninvasive Tool for Evaluation of Edema in Children with Nephrotic Syndrome.

This study aimed to evaluate available volume status assessment tools in nephrotic syndrome (NS). Sixty children with INS were subdivided into hypovolemic and nonhypovolemic groups based on fractional excretion of sodium (FeNa%); all were studied for inferior vena cava collapsibility index (IVCCI), plasma atrial natriuretic peptide (ANP), and body composition monitor (BCM). Forty-four patients had nonhypovolemic and 16 had hypovolemic states. ANP did not differ between both groups. IVCCI was higher in hypovolemic group (p < 0.001) with sensitivity 87.5% and specificity 81.8% for hypovolemia detection, while BCM overhydration (BCM-OH) values were higher in nonhypovolemic group (p = 0.04) with sensitivity = 68.2% and specificity = 75% for detection of hypervolemia. FeNa% showed negative correlation with IVCCI (r = -0.578, p < 0.001) and positive correlation with BCM-OH (r = 0.33, p = 0.018), while FeNa% showed nonsignificant correlation to ANP concentration. IVCCI is a reliable tool for evaluating volume status in NS and is superior to BCM.

Edema in childhood nephrotic syndrome: possible genes-hormones interplay.

BACKGROUND: The role of atrial natriuretic peptide (ANP) in edema formation in idiopathic nephrotic syndrome (INS) was studied before with conflicting results reported; however, the possible contribution of genes regulating ANP expression and receptors was never explored. METHODS: One hundred children (60 with active INS and 40 in remission) were studied for plasma atrial natriuretic peptide (ANP), urinary sodium, ANP gene A2843G and ScaI polymorphisms, and natriuretic peptide receptor clearance C (-55) A polymorphism. For comparative purposes, 20 healthy controls were studied for ANP levels. RESULTS: ANP was higher in active compared to remission patients (p<0.001). ANP in the healthy control group was significantly lower than the ANP level of active INS (during edema) group (p=0.009) but did not show significant differences when compared to ANP levels of either active INS group after resolution of edema or remission group (p= 0.42 and 0.56, respectively). Urinary sodium levels in edematous patients were significantly lower while ANP levels were significantly higher during edema than after resolution (p< 0.001 for both). Genotypes' frequencies of studied polymorphisms did not differ between active and remission groups. Patients with the A1A1 genotype of ScaI polymorphism had higher ANP levels compared to other genotypes (p =0.01). CONCLUSIONS: During edema, ANP levels are elevated in INS children however this increment is not associated with natriuresis suggesting a blunted renal response to ANP. Polymorphisms of genes regulating ANP levels and receptors don't seem to be implicated in edema formation except for the A1A1 genotype of ScaI polymorphism however, its possible role needs further evaluation.

Sonographic evaluation of diaphragmatic thickness and excursion as a predictor for successful extubation in mechanically ventilated preterm infants.

Sonographic assessment of diaphragmatic thickness and excursion has been found to be an accurate tool in predicting successful extubation of adult patients from invasive mechanical ventilation. We aimed to evaluate the accuracy of sonographic assessment of diaphragmatic thickness and excursion in predicting successful extubation of preterm infants from invasive conventional mechanical ventilation. Preterm infants less than 32 weeks gestation who required invasive conventional mechanical ventilation were evaluated by diaphragmatic sonography within 1 h of their planned extubation. Infants were classified into successful or failed extubation groups based on their ability to stay off invasive mechanical ventilation for 72 h after extubation. Inspiratory and expiratory thickness plus excursion of the right and left hemidiaphragm as well as diaphragmatic thickening fraction (DTF) measures were compared between groups. We included 43 eligible infants, of whom 34 infants succeeded and 9 infants failed extubation. Infants in the successful extubation group had a significantly higher expiratory thickness of the right and left hemidiaphragm, excursion of the right and left hemidiaphragm, inspiratory thickness of the left hemidiaphragm, and DTF of the left hemidiaphragm compared with infants who failed extubation. The receiver-operating characteristic curves showed that excursion of the right and left hemidiaphragm has the highest significant accuracy in predicting successful extubation of preterm infants among all diaphragmatic parameters (AUC is 0.98 and 0.96, respectively; p value < 0.001 for both).Conclusion: We conclude that diaphragmatic excursion is a useful indicator for successful extubation of preterm infants from mechanical ventilation. What is Known: • Invasive mechanical ventilation induces ventilator induced diaphragmatic dysfunction (VIDD) particularly when used for long time. • Assessment of diaphragmatic dimensions and functional activity has been a valuable tool in predicting successful extubation of adult patients from invasive mechanical ventilation. What is New: • Sonographic assessment of diaphragmatic dimensions can be used to predict successful extubation of preterm infants from mechanical ventilation. • Sonographic assessment of diaphragmatic excursion shows the highest sensitivity and specificity in predicting successful extubation of preterm infants.

Comparative Study of the Effects of Continuous Positive Airway Pressure and Nasal High-Flow Therapy on Diaphragmatic Dimensions in Preterm Infants.

OBJECTIVE: Nasal continuous positive airway pressure (nCPAP) and nasal high-flow therapy (nHFT) are the most common forms of noninvasive respiratory support in preterm infants. We conducted this study to compare effects of nCPAP and nHFT on diaphragmatic dimensions as assessed by bedside ultrasonography in preterm infants. STUDY DESIGN: A prospective, randomized crossover study comprised 24 preterm infants. Group 1 (n = 12): started on nCPAP for 60 minutes and then switched to nHFT for 60 minutes. Group 2 (n = 12): started on nHFT for 60 minutes then switched to nCPAP for 60 minutes. Ultrasonographic assessment of diaphragmatic dimensions was performed at the end of each epoch. RESULTS: There were no statistically significant differences in diaphragmatic dimensions at the end of each epoch of nCPAP or nHFT. The diaphragm thickening fraction (DTF) was not significantly different with either nCPAP or nHFT [23.4 (13.7-28.0) versus 23.4 (11.2-31.6), p = 0.57]. No significant differences were found regarding heart rate, respiratory rate, Silverman-Anderson scores, and SpO2 on nCPAP and nHFT. All infants enrolled tolerated the crossover maneuver. CONCLUSION: Stable preterm infants (30.3 ± 2.2 weeks' gestation) with mild respiratory dysfunction show comparable effects on diaphragm thickness and excursion during relatively brief periods of support on nCPAP or nHFT. CLINICAL TRIAL REGISTRATION: Registry name: Clinical Trials.gov. Registration number: NCT02421328. Web link to study on registry: https://clinicaltrials.gov/ct2/show/NCT02421328.

Sonographic Evaluation of Diaphragmatic Excursion and Thickness in Healthy Infants and Children.

OBJECTIVES: M-mode sonography is a noninvasive method for detection of diaphragmatic excursion and thickness. A few studies have assessed diaphragmatic kinetics in children with diaphragmatic paresis and paralysis, but to our knowledge, no data about normal values in pediatrics are available. The aims of this study were to determine reference values for diaphragmatic excursion and thickness, as evaluated by sonography in healthy infants and children, and identify correlations between them and anthropometric measurements, age, and sex. METHODS: A total of 400 healthy participants aged between 1 month and 16 years, divided into 4 equal groups (group 1, 1 month-2 years; group 2, 2-6 years; group 3, 6-12 years); and group 4, 12-16 years) were studied. M-mode sonography was used to measure the excursion and thickness of the right and left hemidiaphragms (using the liver and spleen as acoustic windows, respectively). RESULTS: Reference values for diaphragmatic excursion and thickness were determined in different age groups of healthy infants and children. There were no significant differences with respect to sex. Significant positive correlations were found between excursion of the right hemidiaphragm and body weight in all age groups (r = 0.52, 0.25, 0.27. and 0.20; P < .001, .013, .011, and .047 for groups 1-4, respectively). We plotted percentile curves for right diaphragmatic excursion against body weight. CONCLUSIONS: This study provides reference values for diaphragmatic excursion and thickness in healthy infants and children. Percentile curves for right diaphragmatic excursion plotted against body weight were plotted.