CAPD in saudi arabian children: ten years experience from a single center.

In this paper we describe our experience with chronic ambulatory peritoneal dialysis (CAPD) in children. Between 1984 and 1993, a total of 51 patients were treated by CAPD at King Khalid University Hospital. Eight patients were excluded from the study because of incomplete data. There were 25 boys and 18 girls aged three months to 16 years; 12 patients (27.9%) were below two years, 15 patients (34.9%) were between 2-6 years, and 16 patients (37.2%) were above six years of age. Reflux nephropathy secondary to obstructive uropathy was the main cause of ESRD in the study patients (27.9%). The total period of CAPD was 579 patient-months (48.25 years). The overall incidence of peritonitis was high, one episode per 4.7 patient months; one episode per 3.2 patient months in the first five years of the study and one episode per 6.2 patient-months in the 2nd five years of the study period. The cause of peritonitis was gram positive organisms in 38.7% and gram negative organisms in 24.9%. Seventeen (39.5%) of catheters were changed because of infection or mechanical obstruction. In 90.7% of patients, the mother was the person who was performing dialysis. At the end of the study, seven patients (16.2%) were still on CAPD, 10 patients (23.3%) shifted to heraodialysls, 16 patients (37.2%) were transplanted, six patients (14.0%) died and four patients (9.3%) recovered. We conclude that CAPD may be a suitable renal replacement therapy for children in a country with a wide geographical area and low population density as Saudi Arabia.

Association of multicystic dysplasia and crossed nonfused renal ectopia: a case report.

Crossed renal ectopia is an unusual anomaly, 90% of which is fused to the ipsilateral kidney. Multicystic dysplasia in association with crossed non-fused renal ectopia is a very rare phenomenon and can produce a palpable abdominal mass. We report a 2-year old girl who presented with a mass in the abdomen. Detailed evaluation including laparotomy confirmed a diagnosis of multicystic dysplasia in a crossed non-fused ectopic kidney. This diagnostic entity should be considered, when a mass is found in the abdomen or pelvis, and when no kidney can be found in it's normal ipsilateral position.

Acrorenal syndrome associated with visual defect.

The clinical biochemical, radiological, and histological data of a 5-year-old boy with severe limb deformities and renal failure due to oligomeganephronia and renal hypoplasia are reported. This patient represents another example of acrorenal syndrome. This boy has a severe visual defect due to pigmentory retinopathy, which has not been reported previously.

Coagulopathy of childhood nephrotic syndrome--a reappraisal of the role of natural anticoagulants and fibrinolysis.

In an attempt to characterise further the coagulopathy of childhood nephrotic syndrome, this study concentrates on simultaneous measurements of the natural anticoagulants [antithrombin III (ATIII), proteins C and S] and the fibrinolytic factors, tissue plasminogen activator (tPA) and plasminogen activator inhibitor (PAI). The study groups consisted of 41 children (ages ranging from 2 to 14 years; median 7.1) in the relapse of nephrosis and 48 children (ages ranging from 3 to 14 years; median 7.6) in remission. The results obtained were compared with normal values obtained in healthy age- and sex-matched controls (n = 103). During relapse, there was a marked increase in the plasma level of fibrinogen, protein C, and protein S and reduced plasma ATIII level; tPA level was similar to control but PAI level exhibited a significant reduction. During remission, the protein C level either remained elevated or increased further, but some decreased. Protein S and plasma ATIII level normalised. The fibrinolytic activator tPA dropped slightly but the PAI level remained significantly below control levels. We conclude that in the relapse of childhood nephrosis, despite the existence of a significant prothrombotic tendency as featured by hyperfibrinogenaemia and markedly reduced ATIII level, the simultaneous elevation of the natural anticoagulant, protein C level and enhanced fibrinolysis that persist until the remission phase, seem to be major preventive mechanisms guarding nephrotic children against thromboembolic phenomena.

Normal levels of the natural anticoagulants (proteins C & S and antithrombin III) and the fibrinolytic factors (tPA and PAI) in Arab children.

The diagnosis of many hemostatic defects in infancy and childhood depends on the establishment of normal levels of various hemostatic factors. In this study, measurements of the natural anticoagulants (proteins C, S, and antithrombin III), as well as the fibrinolytic factors (tPA and PAI) were undertaken in healthy neonates (cord blood; n = 56), as well as in healthy children, up to 12 years of age (n = 103). The results were compared to normal adult values obtained from blood donors (n = 49). Neonatal values were found to be 50% of those obtained in adults and their mean concentrations were as follows: ATIII antigen = 48.4%, ATIII activity = 61.6%, protein C antigen = 47.7%, protein C activity = 57.2%, total protein S = 41.8% and tPA = 1.9 ng/mL. PAI level (25.7 ng/mL) was similar to adult values. In the first three years of life, almost all the hemostatic factors, other than PAI, gained adults levels. The diminished concentrations of the natural anticoagulants, in addition to the hypofibrinolysis in neonates, shifts the hemostatic balance towards fibrin formation and safeguards effective hemostasis. The values obtained in this study may serve as local reference values.

Bacteriologic profile and drug resistance in pediatric patients with symptomatic bacteriuria.

The bacteriologic profile in 1081 pediatric patients with culture-positive symptomatic bacteriuria was studied over a 30-month period in a 500-bed acute care hospital in Riyadh, Saudi Arabia. Microbial isolates were considered significant if their numbers equaled or exceeded 10,000 colony-forming units/mL in symptomatic patients. Escherichia coli was the most common causative agent of urinary tract infections (55.1%), followed by Pseudomonas aeruginosa (11.9%), Klebsiella pneumoniae (10.0%), and Enterococcus species (6.1%). Results of antimicrobial susceptibility testing indicated that nitrofurantoin and cephradine may be used as empiric therapy pending laboratory investigation; gentamicin can be added in the treatment in severely ill inpatients, and treatment can be modified when microbiologic results become available.

Childhood renal diseases in Saudi Arabia. A clinicopathological study of 167 cases.

Between April 1982 and September 1994, 167 renal biopsies were performed in 167 children at King Khalid University Hospital, Riyadh, Saudi Arabia. The data were analysed to show a correlation between clinical presentation and histological findings. Nephrotic syndrome was the most common indication for renal biopsy, accounting for 77% of all cases. Of these, 23.3% showed minimal change lesions, 24% showed mesangial proliferative glomerulonephritis and 24% showed focal segmental glomerulosclerosis. We noted a higher incidence of congenital nephrotic syndrome and Alport's syndrome as compared with the West. On the other hand, IgA nephropathy was less common (3%), and there was a complete absence of type II membranoproliferative glomerulonephritis.

Nephrolithiasis in children and adolescents in the South Western region of saudi arabia.

We reviewed 71 cases of children and adolescents with nephrolithiasis over a 9 year period (1982-1991). The mean age was 12.3 years. The male: female ratio was 2.5:1. Twelve patients (16.9%) had bilateral stones. Fifteen patients (21%) had documented urinary tract infection. Escherichia coli was the most common organism growing in the urine cultures. Five patients had metabolic abnormalities and four had genitourinary developmental anomalies. Of the 45 calculi recovered for analysis, 17 (37.8%) were predominantly calcium oxalate, 14 (31.1%) were mixed calcium oxalate and uric acid stones, two (4.4%) were uric acid, two (4.4%) were calcium phosphate, two (4.4%) were cystine and eight (17.8%) were struvite stones. Four patients passed their stones spontaneously. Forty-eight underwent open surgery, with complete stone clearance in 45 patients. Two patients needed nephrectomy, seven had their stones removed by endourological procedures, nine patients were referred to other centers for extra corporeal shock wave lithotripsy, while two did not need any intervention. After the initial hospitalization, 57 patients continued follow up for a mean period of 3.3 years. Of them sixteen patients (28.1%) had recurrence of stone disease. We conclude that renal stone disease in children in our area was not uncommon. The majority were calcium oxalate stones. The clinical manifestations were not specific. Open surgery was needed in the majority of patients. Due to significant recurrence rate, long term follow-up was essential. Follow up by a pediatric nephrologists and/or urologist would be advisable.

Acute viral hepatitis, glucose-6-phosphate dehydrogenase deficiency and prolonged acute renal failure: a case report.

A 10-year-old boy with glucose-6-phosphate dehydrogenase deficiency developed acute renal failure during the icteric phase of non-fulminant hepatitis A infection. He needed peritoneal dialysis for 54 days. Acute tubular necrosis was confirmed by percutaneous renal biopsy. He had complete recovery of his renal function when he was discharged.

Platelet Aggregometry - Dose-related Responses to Arachidonic Acid in Childhood Nephrotic Syndrome.

A recent unexpected finding of inhibited platelet aggregation in response to a single (1.64 mmol/l) dose of arachidonic acid (AA), during the relapse of childhood nephrosis, prompted us to assess aggregation in response to multiple doses of AA: 1.64,0.82,0.41,0.20 mmol/l, in two groups of children, in the relapse (n = 34) or remission (n=41) phase of nephrotic syndrome. During relapse: the highest dose of AA (1.64 mmol/l) evoked reversible and inhibited aggregation in 91% of patients. However, at the lower doses there were enhanced responses as measured by both maximum aggregation (%) and slopes of the aggregation curves. In contrast, during remission, irreversible aggregation was obtained at the highest AA dose, while at the lowest two doses (0.41 and 0.20 mmol/l), no aggregation responses were obtained in 4 (9%) and 7 (17%) patients respectively; in those who responded there was a long lag phase. Healthy controls (n = 21) exhibited their highest responses to 1.64 and 0.82 mmol/l AA and at the lowest AA doses (0.41 and 0.20 mmol/l), a total absence of responses was noted in 40% and 71% of samples respectively. We conclude that during relapse platelet sensitivity, as shown by irreversible aggregation in response to multiple AA doses, shifts towards the lower doses, when compared with healthy controls; while during remission responses fall in-between the relapse and control groups, indicating the maintenance of platelet sensitivity during this phase of nephrosis.

Childhood bacterial diarrhoea in a regional hospital in Saudi Arabia: clinico-aetiological features.

Over a one-year period, 210 paediatric patients, who were admitted with acute diarrhoea to a regional hospital in the south-western region of Saudi Arabia, were retrospectively reviewed for bacterial enteropathogens. Bacterial pathogens were isolated from 66 (31.4%) patients, with Shigella being the most common (17.1%), followed by Salmonella (10.5%), and enteropathogenic Escherichia coli (EPEC) (3.8%). Major clinical findings associated with bacterial diarrhoea are similar to those reported before. Our results suggest that bacterial pathogens constitute a major cause of acute childhood diarrhoea in hospitalized children in Al-Baha province. Further prospective community based studies are needed to identify the pattern and risk factors of acute childhood diarrhoea in the region.

Management of acute childhood diarrhoea in Saudi Arabia: practices versus the WHO recommendations.

The fluid management of 247 infants and children who were admitted to King Fahad Hospital at Al Baha, Saudi Arabia with acute diarrhoea was reviewed. Half of them were infants and 25% were exclusively breast fed. Although dehydration was mild in 149 (60.3%) patients and 227 (92.7%) were at the most moderately dehydrated, as many as 95.8% were given intravenous (IV) hydration at least initially. This indicates that the WHO recommendation to prescribe oral rehydrating solution (ORS) for the control of diarrhoeal diseases, is still not implemented at some of the regional hospitals in Saudi Arabia, and emphasizes the need for urgent and effective efforts to rectify this situation.

PIP: Acute diarrhea remains a major cause of morbidity and mortality among infants and children in developing countries accounting for up to 20% of admissions to pediatric wards in Saudi Arabia. Oral rehydration therapy is recognized by the WHO as being a safe and effective way to treat this manifestation of infectious disease, but many physicians are reluctant to adopt its practice. 247 of the infants and children admitted to King Fahad Hospital at Al Baha, Saudi Arabia between July 1, 1990 and June 30, 1991, suffered from acute diarrhea. This paper reviews the fluid management of these patients to determine whether and to what extent WHO guidelines are being followed. Half of the patients were infants and 25% were exclusively breastfed. The mean duration of diarrhea at the time of presentation was 3.8 days in a range of 1-8 days. Although only mild dehydration was observed in 149 of the patients and moderate dehydration in 227, 95.8% were nonetheless given intravenous hydration initially for the first 24 hours. These findings suggest that the WHO recommendation to prescribe oral rehydration solution to control diarrheal diseases is not being implemented at some regional hospitals in Saudi Arabia.

Pediatrics inpatients at the King Khalid University Hospital, Riyadh, Saudi Arabia, 1985-1989.

A review of admissions into the pediatric wards of the King Khalid University Hospital (KKUH), Riyadh, Saudi Arabia, over a four-year period (1985-1989) indentified perinatal problems, acute respiratory infections, congenital anomalies and diseases of the central nervous system, as the major disorders. With the notable exception of nutritional rickets, manlnutrition was rare. The age distribution showed a preponderance of neonates and infants who represented 42.1% and 53.6% of all admissions, respectively. There was a seasonal variation with more patients being admitted during the cool months of November-April than the hot months of May-October, and acute respiratory infections were found to be mostly responsible for this seasonality. Genetic and heredofamilial factors features prominently in the pathogenesis of many of the disorders for which the children were admitted. It is therefore recommended that increased attention be given to neonatology and to genetics and genetic counselling as important components of medical practice in the country. The establishment of a National Institute for Human Genetics is also highly desirable.

Visceral leishmaniasis in infancy and childhood epidemiology and clinicopathological study of 63 cases in Al-Baha Province, Saudi Arabia.

The epidemiology, clinicopathological features, and response to therapy of 63 Saudi patients with visceral leishmaniasis are described. The clinical features in our cases were similar to those described from Asir province, India, and Ethiopia, except for the presence of lymphadenopathy. Fever, hepatosplenomegaly, pancytopenia, and liver dysfunction were common findings. The unusual feature is the seasonal variation in the distribution of the disease. The response to sodium stibogluconate was excellent and the mortality rate was low (less than 1 per cent).

Ultrasound detection rate of childhood urolithiasis.

A retrospective study of 42 children with 45 proven urinary tract stones who had had intravenous urography (IVU), ultrasound examination and a plain abdominal X-ray (KUB) was undertaken in order to evaluate the prediction rate of each method. Ultrasound was more sensitive than KUB (91% vs 80%) in detecting stones. All renal stones were detected by ultrasound. KUB was superior to ultrasound in detecting ureteral stones (66.6% vs 55.5%). All stones were detected by the combination of ultrasound and KUB. Two renal radiolucent stones were missed by IVU. The results of this study suggest that the combination of ultrasound examination and KUB is more sensitive in detecting stones than IVU and is more convenient and less invasive.

Henoch-Schönlein syndrome in Saudi Arabia.

A retrospective study was carried out on 40 children from Saudi Arabia with Henoch-Schönlein syndrome to delineate its clinical pattern. More than 50 per cent of the cases occurred in winter. There was no apparent causal relationship with B-haemolytic streptococcal infection. All patients had skin rash. Fifty-eight per cent had gastrointestinal manifestations, 58 per cent had joint manifestations and 38 per cent had renal manifestations. The main clinical features of Henoch-Schönlein syndrome in Saudi children are comparable to those reported elsewhere.

Postrenal-biopsy hematoma in infants and children: evaluation by ultrasonography.

Postbiopsy hematoma was assessed using ultrasonography in 106 infants and children (age 1 month to 15 years) who underwent a total of 122 percutaneous renal biopsies. Postbiopsy hematoma occurred in 22 (21%) of 105 successful biopsies. However, only 2 of these were symptomatic. Renal failure, mild and moderate hypertension and inexperience of the operator were not found to increase the incidence of postbiopsy hematoma in infants and children.

Sonographic findings in infantile idiopathic nephrotic syndrome.

Abnormal sonographic findings were obtained in all cases of infantile idiopathic nephrotic syndrome (IINS). Hyperechoic renal parenchyma, subcapsular hypoechoic band and loss of cortical medullary differentiation were the commonest abnormalities. There was no specific sonographic difference between the different types of IINS. The subcapsular hypoechoic band is also not diagnostic for IINS. Abnormal sonographic findings indicate renal biopsy to identify specific types of IINS.

The outcome of percutaneous renal biopsy in children: an analysis of 120 consecutive cases.

One hundred and twenty percutaneous renal biopsies performed in 104 patients aged 1 month to 15 years were analysed. Ultrasound examination was used for localization of the kidneys. Adequate renal tissue was obtained in 103 biopsies, with an overall success rate of 85.8%. The most frequent complication was gross haematuria, which occurred in 32 biopsies, but only 5 children required blood transfusion. Nineteen patients developed perirenal haematoma; 2 of these were symptomatic. Arteriovenous fistula was diagnosed in 2 patients. One patient died secondary to intestinal perforation. Serious complications were noted in patients with chronic renal failure. The success and complication rates in 10 patients less than 1 year of age were comparable with the rest of the group. The frequency of serious complications on renal biopsy in the present study was slightly higher than in the more developed countries.