Fibroblast Growth Factor 23 Level and Cardiovascular Parameters in Children with Chronic Kidney Disease.

OBJECTIVE: To find out the serum fibroblast growth factor 23 (FGF-23) levels in different grades of CKD, and the prevalence of abnormal left ventricular mass index (LVMI), carotid intima-medial thickness (cIMT), and central pulse wave velocity (cPWV) and the risk factors including FGF-23 for these abnormalities. METHODS: Fifty-nine patients of CKD with G2 to G5, aged 2-18 y were included. The LVMI, cIMT, and cPWV were measured using standard techniques, and serum intact FGF-23 levels were estimated at enrollment. RESULTS: Median FGF-23 levels were significantly raised in all the grades of CKD than controls (p < 0.001), and also in G4 and G5 in comparison to G2&3 and in G5D than G5. Increased LVMI in 42 (71.2%), elevated cIMT in 30 (57.7%), and cPWV in 14 (26.9%) patients were found. The FGF-23 showed significant negative correlation with eGFRcr and positive with serum iPTH, phosphate and alkaline phosphatase levels, but had no correlations with LVMI, cIMT SDS, and cPWV SDS. Only systolic BP SDS (odds ratio 1.5, 95% CI 1.008-2.231, p = 0.046) was observed as a significant predictor for increased cIMT, while no variables had any association with abnormal LVMI and cPWV. CONCLUSIONS: Serum FGF-23 showed higher levels with increasing grades of CKD, but no significant association with cardiovascular parameters. Systolic BP SDS was found as a significant risk factor for increased cIMT in children with CKD.

Clinico-mycological study of dermatophytic infections and their sensitivity to antifungal drugs in a tertiary care center.

BACKGROUND: Worldwide, dermatophytic infections are running a chronic course either due to ineffective treatment or emerging drug resistance. In the past three decades, there has been an increase in incidence and non-responsiveness to conventional antifungals, which suggests that there is a need of antifungal sensitivity testing. AIMS: This study was aimed at identifying clinico-mycological pattern of dermatophytic infections in patients attending thedermatology outpatient department of a tertiary care hospital, and to obtain the sensitivity pattern of isolates against six commonly used oral antifungals (fluconazole, terbinafine, itraconazole, ketoconazole, griseofulvin and voriconazole). METHODS: Patients with suspected dermatophytoses attending the outpatient department of Sir Sunderlal Hospital, Varanasi, were enrolled in the study. A detailed history, clinical examination and sample collection for mycological examinations was done. In vitro antifungal sensitivity testing was done on species isolated from culture as per the Clinical and Laboratory Standard Institute M38-A standards, with broth microdilution method. RESULTS: There were 256 patients recruited in the study, with a male: female ratio of 3:1. The most commonly affected age group was 20-40 years (52.4%). Tinea corporis et cruris was the most common type observed (27.2%). Potassium hydroxide positivity was seen in 211 samples (79.6%) and culture positivity was found in 139 samples (52.4%). The most common species identified was Trichophyton mentagrophytes (75.9%). Sensitivity testing was done on fifty isolates of T. mentagrophytes. Minimum inhibitory concentrations of itraconazole, ketoconazole, terbinafine and voriconazole were comparable, while griseofulvin showed the highest minimum inhibitory concentration. Itraconazole was found to be the most effective drug, followed by ketoconazole, terbinafine and fluconazole. Griseofulvin was the least effective drug among the tested antifungals. LIMITATIONS: This is a hospital-based study, and may not reflect the true pattern in the community. Sensitivity pattern of only one species T. mentagrophytes was carried out. CONCLUSION: Inadequate and irregular use of antifungal drugs has led to the emergence of resistant strains, which cause poor treatment outcomes. Thus, it is very important to test for antifungal sensitivity to check for resistance to antifungals.

Predictive ability of urinary biomarkers for outcome in children with acute kidney injury.

BACKGROUND: Urinary neutrophil gelatinase-associated lipocalin (NGAL), N-acetyl-beta-D-glucosaminidase (NAG), and interleukin 18 (IL-18) were found to be useful for early detection of acute kidney injury (AKI). The objective of this study was to determine the predictive ability of biomarkers for mortality and variation in levels in relation to different stages of AKI, need for dialysis, etiologies, and with duration of hospital stay. METHODS: Urinary NGAL, NAG, and IL-18 levels were measured in 50 children with AKI and 30 age- and gender-matched healthy controls. AKI was classified as per pediatric Risk, Injury, Failure, Loss, and End-stage (RIFLE) criteria. RESULTS: Median NGAL, NAG, and IL-18 values were significantly increased in AKI patients compared with controls (p < 0.001), with significant increase among risk, injury, and failure stages. Nonsurvivors had significantly higher median levels of NGAL (p = 0.008) and NAG (p = 0.018) than survivors. NGAL had highest area under the curve (AUC) at 0.750 [confidence interval (CI) 0.580-0.920], followed by NAG at 0.724 (CI 0.541-0.907), with sensitivity and specificity of 75 % each; and IL-18 (AUC 0.688, CI 0.511-0.864), with sensitivity 62.5 % and specificity 70.8 %, for predicting mortality. Values were significantly higher in patients who required peritoneal dialysis (PD) than in those in whom it was not indicated. Levels were comparable among different etiologies. Only NGAL level was found to be a significant risk factor associated with longer duration of hospital stay. CONCLUSIONS: Urinary NGAL and NAG had modest predictive ability for mortality. Children requiring dialysis had significantly raised levels, and the NGAL level had significant association with duration of hospital stay.

Can we predict relapses in children with idiopathic steroid-sensitive nephrotic syndrome?

The objective of the present study was to find out the predictors of relapse. One hundred fifty children with a first episode of idiopathic nephrotic syndrome were followed for 12 months after initial treatment. Sixty-one (40.7%) children had no relapse, and 89 (59.3%) had relapses. A significantly higher proportion of children with disease onset between 1 and 3 years were relapsers in comparison with those with disease onset at 4-6 (p < 0.03) and 7-13 (p < 0.001) years. Risk of relapse was 2.99 times higher in this 1-3 year age-group as compared with patients aged >6 years (p = 0.001). Children responding between 1 and 2 weeks after start of treatment had a 0.423 times lesser risk of relapse than those who responded after 4 weeks (p = 0.023). Relapsers had significantly higher incidence of infection at relapse than at other time points (p < 0.001). Onset of disease in younger age and delayed response to prednisolone therapy were found as significant predictors for relapse.

Prolonged versus standard prednisolone therapy for initial episode of idiopathic nephrotic syndrome.

BACKGROUND: The prolongation of steroid therapy for an initial episode of idiopathic nephrotic syndrome may decrease any relapses. Two treatment protocols were compared with the objective of finding the frequency of relapses and side effects of steroid in the following 12-month period. METHODS: A hospital-based prospective study was conducted of 80 children allocated randomly to receive prolonged (5-month) or standard (3-month) prednisolone therapy. They were followed quarterly for 12 months during which the numbers of relapses and steroid side effects were noted. RESULTS: The mean relapse rate (0.63 vs. 1.54; p=0.011) and cumulative risk of relapse per patient per month (0.05 vs. 0.131) were significantly lower in the prolonged than the standard treatment. Total relapses in patients followed up for 12 months were significantly lower in the prolonged-therapy as compared with the standard-therapy group (21.6% vs. 70.2%; p=0.001). Cumulative percentage of patients with sustained remission at 12 months was significantly higher in the prolonged-therapy than the standard-therapy group (76% vs. 29%). Mean cumulative dose of prednisolone with prolonged therapy was significantly lower than with standard treatment (p=0.033). Steroid side effects such as cushingoid appearance, hirsutism, striae and hypertension were comparable in both treatment groups. CONCLUSIONS: A prolonged course of prednisolone therapy for an initial episode of nephrotic syndrome can be considered, as it reduces the rate of relapses without increasing the risk for steroid side effects.

Lay perceptions of kala-azar, mosquitoes and bed nets in Bihar, India.

OBJECTIVE: To describe the lay perception of kala-azar (KA) in an endemic area of Muzaffarpur District, Bihar, India: local names, symptoms, affected persons, perceived severity and modes of transmission, as well as perceived mosquito nuisance, modes of protection and use of bed nets. METHODS: We held 16 focus group discussions (FGD) in eight remote villages with altogether 157 participants in March 2008. Separate FGDs were held according to gender, socio-economic status (SES) and with key informants. RESULTS: Kala-azar is most commonly named pilahi. Poor people were said to be the most affected. Knowledge about symptoms was satisfactory. Fever and prolonged fever were the most stated symptoms. KA was perceived as a life-threatening disease with a heavy economic burden. Mosquito bites were perceived as the main mode of transmission but in lower socio-economic groups, non-vector-related explanations were also provided. The main modes of protection from mosquitoes mentioned were the use of fumes and bed nets. Season was the strongest factor influencing the use of bed nets and non-affordability for not owning them. CONCLUSIONS: Although the sand fly is not recognised as the vector, the relatively good awareness of disease transmission by mosquitoes and the nuisance caused by their high density might be an entry point for adopting preventive measures to protect from mosquito bite and thereby indirectly preventing from KA. Educational campaigns targeted to the poorer segments of society are needed to enhance knowledge about KA, its mode of transmission, risks of getting infected and to increase bed net use.

Knowledge, attitude, and practices related to Kala-azar in a rural area of Bihar state, India.

The Indian Government aspires to eliminate Kala-azar by 2010. Success of any disease control program depends on community participation, and there is no published data about the knowledge, attitude, and practices of the community about Kala-azar in endemic regions of India. For this knowledge, attitude, and practices (KAP) study, the heads of 3,968 households in a rural area, consisting of 26,444 populations, were interviewed using a pre-tested, semi-structured schedule. Most of the study subjects (97.4%) were aware of Kala-azar. Fever (71.3%) and weight loss (30.5%) were the most commonly known symptoms. The infectious nature of the disease was known to 39.9%. The majority believed that the disease spreads by mosquito bites (72.8%). For 63.6%, the breeding site of the vector was garbage collection. Only 23.6% preferred the public health sector for treatment, and 55.9% believed that facilities at primary health centers are not adequate. Poor knowledge of the study subjects about the disease and breeding sites of the vector underscores the need for health educational campaigns if the elimination program is to succeed.