A 30-year retrospective study on causes of death in childhood-onset systemic lupus erythematosus in a tertiary care centre in Southern Thailand.

OBJECTIVES: We set out to determine the causes of death in childhood-onset systemic lupus erythematosus (cSLE). METHODS: The medical records of children aged <18 years who were diagnosed with SLE from 1985 to 2016 in the Division of Nephrology, Department of Paediatrics, Faculty of Medicine, Prince of Songkla University, Thailand, were reviewed. RESULTS: There was a total of 331 patients, 272 girls and 59 boys, of whom 77 (23.3%) died, 28.6% within the first year after diagnosis. Only 29 medical records of the 77 confirmed-death patients were available for evaluation of cause of death; 7 boys and 22 girls, with a mean age at presentation of 10.9±3.1 years. The mean follow-up duration was 4.6±3.7 (range 0.2-12.6) years. The major cause of death was sepsis (n=13 patients with 15 identified organisms, which were Acinetobacter baumannii (9), Escherichia coli (3), Candida albicans (2) and Aspergillosis (1)), followed by acute respiratory distress syndrome (ARDS) (6), severe heart condition (3), acute kidney injury (AKI) (2), chronic kidney disease (CKD) (2) and intracranial haemorrhage (1). Conditions at the time of death were sepsis (25), pneumonia (16), AKI (15), bleeding disorders (11), neurological complications (10), ARDS (10), CKD (4), AKI in addition to CKD (3). CONCLUSIONS: The cause of death in cSLE is usually multi-factorial and it is difficult to assign a single dominant cause. Sepsis was the most common cause of death and, together with sepsis-related organ failure, was the most common condition at the time of death. The most common organism was Acinetobacter baumannii.

Characteristics and Findings of Childhood Urinary Tract Infection in the Last Decade.

BACKGROUND: The strong association between kidney and urinary tract anomalies and childhood urinary tract infection (UTI) often leads to imaging tests being performed. -Objective: To describe the epidemiology, characteristics, and imaging findings in Thai children with UTI and compare results between boys and girls. METHODS: We retrospectively reviewed the medical records of children with UTI aged < 15 years. Demographic characteristics and findings of investigations are presented. RESULTS: One hundred seventy-eight boys and 170 girls with 432 UTI episodes were identified. The median (interquartile range) age at presentation was 1.4 (0.6-3.4) years, 1.0 for boys and 2.1 for girls (p < 0.001). Renal ultrasound, voiding cystourethrogram and 99mTc dimercaptosuccinic acid (DMSA) renal scans were performed in 273, 223 and 113 children, respectively. Overall, 283 children (81.3%) had at least one imaging study done and anomalies of the kidney and urinary tract were detected in 158 (45.4%). Primary vesicoureteral reflux was detected in 73 (32.7%) children. The remaining abnormalities were hydronephrosis (n = 54). DMSA scans detected 54 children with dysplastic or scarred kidneys. CONCLUSIONS: First UTI in a group of Thai children occurred in approximately equal proportion in boys and girls but boys were younger at diagnosis. Kidney and urinary tract anomalies were detected in half of the children.

Improvement of survival rates in the last decade in Thai childhood-onset systemic lupus erythematosus.

BACKGROUND: Morbidity and mortality in childhood onset systemic lupus erythematosus (SLE) is more severe than adult onset SLE. Long-term follow up is needed to determine the prognosis. The objectives of this study are to describe the mortality of childhood SLE in a single tertiary care centre over three decades, compare trends in survival over time, and determine predictors for survival. METHODS: We retrospectively reviewed the medical records of children aged < 18 years who were diagnosed with SLE at the Department of Pediatrics, Songklanagarind Hospital, Thailand, from 1985 to 2016. RESULTS: There were 331 children (272 girls, 59 boys) with a mean age at presentation of 11.5 ± 2.6 years. The mean follow-up duration was 7.0 ± 5.0 (range 1-28) years, 77 children (23.3%) died, 28.6% within the first year after diagnosis. The overall mortality rate was 3.3 per 100 person-years. Survival rates at 1, 5 and 10 years were 93.4%, 83.1% and 72.6%, respectively. Ten-year survival rates for the children diagnosed in the decades 1985-1996, 1997-2006 and 2007-2016 were 67.4%, 63.4% and 82.8%, respectively (p < 0.001). Boys had worse survival than girls (hazard ratio = 2.3, 95% CI: 1.4-3.7) even after adjusting for decade of diagnosis. Lupus nephritis (LN) class IV had similar survival compared to LN classes II/III/V combined (hazard ratio = 1.0, 95% CI: 0.6-1.7). CONCLUSION: In our setting, the survival rate of childhood onset SLE has improved during the past 10 years, but mortality is still high compared to developed countries, particularly in boys.

What Did We Find From Imaging Studies in Childhood Urinary Tract Infection and Which Studies Are Mandatory?

OBJECTIVE: To evaluate the imaging results of childhood urinary tract infection (UTI) in our setting, and examine if it would be appropriate to apply the recent guideline changes regarding imaging studies as routine practice in Thailand. METHODS: Medical records of children with UTI aged 0-15 years were reviewed, with focus on renal ultrasound (RUS), cystogram, and 99mTc dimercaptosuccinic acid (DMSA) renal scan results to determine congenital anomalies of the kidney and urinary tract (CAKUT) and renal damage. Mild CAKUT was defined as primary vesicoureteral reflux grades I-III or isolated hydronephrosis, and all other abnormalities were defined as severe CAKUT. RESULTS: A total of 142 boys and 129 girls had at least 1 imaging study after UTI. Their median (interquartile range) age was 1.0 (0.5-2.7) year: 0.7 and 1.4 years for boys and girls, respectively (P = .006). A total of 262 children had an RUS performed, of which 99 (37.8%) were abnormal. Cystograms were performed in 221 children, from which 83 (37.6%) CAKUTs were detected, and 108 children had a DMSA performed, of which 53 (49.1%) were abnormal. Overall, CAKUTs were detected in 148 (54.6%) children, of which 43 were severe. RUS together with cystogram provided higher sensitivity (100% vs 88.9%) and specificity (53.8% vs 42.4%) to detect severe CAKUT than RUS together with DMSA. CONCLUSION: A CAKUT was detected in more than half of the children with first UTI, with one-third having severe CAKUT. In our setting, RUS combined with cystogram is still the most reliable way to detect potentially harmful post-UTI problems, and the new western guidelines are not appropriate.

Primary vesicoureteral reflux: A 26-year experience in a single centre.

AIM: To determine the nature of primary vesicoureteral reflux (VUR) and the association of VUR with hydronephrosis and renal damage. METHODS: The medical records of children ≤ 15 years diagnosed with VUR, attending the Department of Pediatrics, Prince of Songkla University, Thailand between 1987 and 2013 were reviewed. Renal ultrasound and technetium-99m dimercaptosuccinic acid renal scan (DMSA) results were examined to determine the severity of hydronephrosis and renal damage, respectively. RESULTS: There were 177 boys and 211 girls. 350 (90.2%) were diagnosed following urinary tract infection (UTI). The median (IQR) age at diagnosis of first VUR was 7.6 (4.3-12.2) months in boys and 18.6 (9.0-46.6) months in girls (P < 0.001). Renal ultrasound was performed in 340 patients. Hydronephrosis was found in 105 patients and 135 kidneys and 22.5% VUR kidneys and 11.0% non-VUR kidneys (P = 0.01). The severity of hydronephrosis was associated with VUR grade (44.2% of grades IV and V VUR had hydronephrosis vs 11.9% of grades I-III VUR, P < 0.001). DMSA was performed in 332 patients. Abnormalities were found in 30.1% VUR kidneys and 4.1% non-VUR kidneys (P < 0.001). Abnormal DMSA results were strongly associated with VUR grade (17.8% for VUR grades I-III vs 60.5% for VUR grades IV and V, P < 0.001). CONCLUSION: Primary VUR in this group was most commonly diagnosed following investigation of UTI and detected during infancy, earlier in boys. Hydronephrosis and renal damage were associated with severity of VUR.

Tuberculosis in SLE patients: rare diagnosis, risky treatment.

We document three cases of tuberculosis (TB) in 237 systemic lupus erythematosus (SLE) patients. Their ages at SLE and TB diagnoses were 13/15, 10/25, and 13/24 years. All were female and in all the TB was diagnosed during a period of lupus flare-up when they were receiving prednisolone and other immunosuppressive drugs. All three patients had extrapulmonary TB: Two had miliary TB and one had disseminated TB through the muscles, left knee joint, and lungs. All three patients experienced anti-TB drug-induced hepatotoxicity manifesting as jaundice along with elevated transaminase enzymes from the first-line anti-TB drugs they received, leading to a change to second-line drugs in two of them. In conclusion, although TB in SLE patients is not common, it should be considered when a patient is nonresponsive to the SLE treatment. Higher rates of extrapulmonary TB and anti-TB drug-induced hepatotoxicity in SLE patients with TB were noted.

Systemic lupus erythematosus-related pancreatitis in children.

We report on three patients who developed four episodes of acute pancreatitis while their systemic lupus erythematosus was active and being treated with prednisolone. In all three, gastritis was first considered and treated due to abdominal pain, vomiting, and epigastric tenderness, but their symptoms did not improve. Then pancreatic enzymes were measured, which confirmed pancreatitis. Imaging studies showed an enlarged pancreas in one case, a normal pancreas in two cases, and a focal hypodense nonenhancing parenchyma in one case. Corticosteroids were prescribed for both active SLE and SLE-related pancreatitis. Pulse methylprednisolone was prescribed in one episode, increasing oral prednisolone in one episode, and the same dose of prednisolone continued in the other two episodes. All cases recovered without complications. SLE-related pancreatitis should be considered in SLE patients when the SLE is active and a patient develops abdominal pain and vomiting.

Intravenous cyclophosphamide combined with steroids in pediatric onset severe lupus nephritis.

BACKGROUND: Intravenous cyclophosphamide (IVCY) has been used to treat severe lupus nephritis (LN) for many years. Because of the wide variety of manifestations of the condition and the long-term nature of the disease, outcomes vary widely. OBJECTIVE: To evaluate and compare the immediate and long-term results of IVCY in pediatric onset severe LN and between patients with normal and abnormal initial renal function. METHODS: Patients aged <18 years who attended the Department of Pediatrics, Prince of Songkla University, diagnosed with severe LN, and who were given a 36-month IVCY course, were included. Comparison of overall survival between the two groups was assessed using Kaplan-Meier survival curves. RESULTS: 108 patients with a mean age of 12.6 ± 2.7 years were studied, with a mean follow-up time of 5.7 ± 4.3 years. 48 patients completed the IVCY course. 36 patients had abnormal renal function and 72 patients had normal renal function at the start of therapy. Both groups responded well initially to treatment; proteinuria reduced to normal levels after 1 and 2 treatments in the normal and abnormal groups, respectively, while creatinine clearance returned to normal levels after 8 treatments in the abnormal group. Overall survival was not different between the two groups; however, the abnormal renal function group had a higher crude mortality rate than the normal group (13/36 vs 10/72, p value = 0.02). At the time of analysis, some patients who had completed their IVCY course still required other therapy to control their disease activity. CONCLUSION: Three years of IVCY treatment provided similar outcomes in both normal and abnormal renal function groups. Immediate outcomes were favorable but long-term remission was not promising.

Childhood recurrent urinary tract infection in southern Thailand.

INTRODUCTION: Recurrent urinary tract infection (UTI) is one of the major health problems in children because of its high rate of occurrence. OBJECTIVE: Our aim of the study was to evaluate the prevalence and determine risk factors of recurrent UTI in Thai children. PATIENTS AND METHODS: The medical records of children aged less than 15 years diagnosed with UTI at the Department of Pediatrics, Songklanagarind Hospital were reviewed. RESULTS: A total of 307 children (144 boys, 163 girls) were followed up for at least 1 year. Fifty-six children, 31 (19.0%) boys and 25 (17.4%) girls, developed at least one recurrence totaling 153 recurrent UTI episodes. The recurrence rate was not statistically different between the sexes (p = 0.8). On multivariate analysis, genitourinary system (GU) anomalies, particularly vesicoureteral reflux (VUR), were the most significant risk factors. Children aged greater than 5 years had a slightly higher risk of recurrence, irrespective of gender. Comparison of organisms associated with recurrent UTI with those associated with first UTI showed that the prevalence of Escherichia coli decreased from 76.9% to 56.2% but was still the major causative agent. In contrast, the prevalence of Klebsiella pneumoniae and unusual or mixed organisms significantly increased from 7.8% to 15.0% and 6.2% to 16.3%, respectively. CONCLUSION: One-fifth of children who had UTI developed recurrence and the rates were similar for males and females. Independent risk factors for recurrent UTI were found to be at age of >5 years and underlying disease of either GU anomaly or VUR.

Neonatal acute kidney injury in a tertiary center in a developing country.

BACKGROUND: Acute kidney injury (AKI) is a common contributor to morbidity and mortality in newborns, with prevalences varying by population and hospital. A study of AKI in newborns in tertiary care centers in Thailand, a developing country with limited resources, has not been conducted yet. METHODS: The aim of this study was to determine the prevalence of AKI in newborns in a tertiary care hospital in southern Thailand and to investigate the etiology, mortality and risk factors of mortality. The records of patients aged <30 days with high serum creatinine, admitted from 1984 to 2007, were retrospectively reviewed. RESULTS: Eighty-eight boys and 51 girls were enrolled; 61.4% were premature and 56.5% had a birth weight <2500 g. The prevalence of newborn AKI increased from 0.9 to 6.3% during the 24-year study period. Thirty-nine and 65% had renal failure within 2 and 7 days post-birth, respectively. Sepsis was the most common cause of AKI (30.9%) followed by hypovolemia (18.7%), kidney, ureter and bladder (KUB) anomalies (12.2%), congestive heart failure (12.2%) and birth asphyxia (11.5%). Indomethacin caused AKI in 24.4% with gestational age <32 weeks. Sepsis-induced AKI had the highest mortality rate (65.1%) with an overall mortality rate of 38.8% and nearly 14 times the risk of death compared to hypovolemia-induced AKI. CONCLUSIONS: The prevalence of newborn AKI in our Thai tertiary center over 24 years was 6.3% of admitted newborns. Sepsis was the most common cause of AKI and sepsis-induced AKI is the most common cause of death. Disease etiology was the only risk factor for mortality.

Twenty-two years' experience with childhood-onset SLE in a developing country: are outcomes similar to developed countries?

INTRODUCTION: The outcome of systemic lupus erythematosus (SLE) has dramatically improved since the introduction of corticosteroids; however, although many regimens of treatment have been supplemented, the mortality has not improved further. OBJECTIVE: To describe the severity and outcome in patients diagnosed with SLE aged ≤18 years in a group of Thai children, compare gender and age differences, and our outcomes with those from developed countries. METHODS: The authors retrospectively reviewed the files of patients aged ≤18 years diagnosed with SLE admitted to Songklanagarind University Hospital in southern Thailand, for the period 1985-2007. Patient survival rates were calculated. RESULTS: There were 213 SLE patients, 41 males and 172 females, average age 11.6±2.6 years, with a median follow-up of 3.6 years. Outcomes were alive (109), lost to follow-up (22), referred (31) or deceased (51). Of the patients who were alive, 23 were not on any treatment, 59 were on prednisolone alone while 27 were on prednisolone plus some other immunosuppressive drug. Total survival rates were 88%, 76% and 64% at 2, 5 and 10 years, respectively. Males had significantly worse survival than females at 2 and 5 years (78% vs 91% and 58% vs 80%, respectively, p=0.018). There were no differences in mortality between age groups. The 5-year survival rates in the periods 1985-1993, 1994-2000 and 2001-2007 were not significantly different. CONCLUSION: This retrospective study of patients with SLE in southern Thailand showed different outcomes compared to some studies and similar survival rates and treatment status to other studies, with one-fourth of surviving patients being free of medication.

Outcome of dengue hemorrhagic fever-caused acute kidney injury in Thai children.

OBJECTIVES: To examine the outcome of acute kidney injury (AKI) in children with dengue hemorrhagic fever (DHF), the cause(s) of AKI, and the risk of AKI and fatality. STUDY DESIGN: The medical records of patients age <15 years during 1989 to 2007 were reviewed. DHF-caused AKI and patients with DHF with no AKI were matched 1:2 by age. RESULTS: DHF-caused AKI was clinically estimated to be 0.9% (25/2893) of admissions, with a high mortality rate of 64.0%. Risk factors of AKI were DHF grade IV and obesity (odds ratio, 16.9; 95% CI, 4.2 to 68.5, and odds ratio, 6.3; 95% CI, 1.4 to 28.8, respectively). Respiratory failure, hepatic failure, and massive bleeding were complications found in 80.0%, 96.0%, and 84.0% of cases with AKI, respectively. Fatality was more likely in cases with DHF grade IV, oliguric AKI, respiratory failure, or prolongation of prothrombin or activated partial thromboplastin time more than twice that of reference specimens. Among the survivors, none had chronic kidney disease, and serum creatinine levels returned to normal in 32 (1 to 48) days. CONCLUSIONS: Patients with DHF and AKI had a high mortality rate, although those who survived had a full return to normal function within 1 month. DHF grade IV and obesity were the major risk factors of AKI.

Is a repeat urine culture useful during antibiotic therapy for febrile urinary tract infection?

AIM: To evaluate the cost-effectiveness of a repeat urine culture after a few days of antibiotic therapy in childhood urinary tract infection (UTI) in southern Thailand. METHODS: A retrospective review of the medical record of children diagnosed with UTI aged less than 15 years in Songklanagarind Hospital from January 1995 to December 2004 was performed. Patient demographics were collected. The results of repeat urine culture after starting antibiotic were evaluated. The risk factors that indicated positive repeat urine culture were determined. RESULTS: Four hundred and forty-nine patients (245 boys and 204 girls) with 533 UTI episodes were analyzed, of which 49 (9.2%) had a repeat urine culture with significant growth. Multivariate analysis showed that age less than 1 year, aetiological agents Enterococci spp., fever of more than 72 h, inappropriate antibiotics and kidney, ureter and bladder anomalies were the most significant risk factors for a positive repeat culture, while sex, vesicoureteral reflux and recurrent UTI episodes were not significant risk factors. If the treatment protocol during the study period had indicated that children with at least one of the above risk factors should receive a repeat urine culture, then only 356 cases (66.8% +/- 2.0%) would have received a repeat test and $US 655 would have been saved, while five positive repeat urine cultures would have been missed. CONCLUSION: The present study in a group of Thai children indicates that a repeat urine culture during antibiotic therapy should still be recommended.

Diffuse proliferative glomerulonephritis does not determine the worst outcome in childhood-onset lupus nephritis: a 23-year experience in a single centre.

INTRODUCTION: Lupus nephritis (LN) is the major indicator of morbidity and mortality in systemic lupus erythematosus (SLE). Many studies have found a significantly worse patient survival rate in patients with LN class IV than patients with other LN classes. OBJECTIVE: The aim was to describe the severity and outcomes of LN in a group of Thai children. METHODS: We retrospectively reviewed the patient files of children diagnosed with SLE aged < or =18 years in Songklanagarind Hospital, Southern Thailand, from 1985 to 2007. RESULTS: Of 216 SLE patients, 180 had renal biopsy results, and the others were excluded from analysis. There were 33 males and 147 females, average age 11.8 +/- 2.6 years (range 3.6-18.0), with a median follow-up period of 3.9 years (range 9 days to 19.4 years). Using the WHO LN classification, there were 9, 55, 5, 94 and 14 patients of classes I-V, respectively, as well as 2 with end-stage renal disease and 1 with IgM nephropathy. The mortality rate was 23% (42/180). Patients with LN class II had a similar renal and patient survival compared to patients with LN class IV (P = 0.3 and 0.2, respectively). Cox proportional hazard regression analysis in 177 patients (3 patients who had a renal biopsy result outside the WHO classification were omitted) showed that gender was an independent risk factor for survival. Males had 2.6 times the hazard rate compared to females (95% CI 1.2-5.7, P = 0.03), but LN classification, age and timing of the renal biopsy were not significant. CONCLUSION: Renal and patient survival in LN classes II and IV were similar. Gender was the only independent risk factor of mortality, with males at greater risk than females.

Fatal infection in children with lupus nephritis treated with intravenous cyclophosphamide.

A knowledge of the causes and risk factors of fatal infection in childhood lupus nephritis (LN) patients treated with intravenous cyclophosphamide (IVCY) is important to enable optimal treatment. During an 11-year period (1996-2007), severe infection cases occurred in 31/84 (36.9%) patients with 64 infection episodes in our central referral institution in southern Thailand. Fatal infections occurred in 13/31 (41.9%) patients, most (11/13, 84.6%) during the first infective episode. The major causative organisms of the fatal infections were fungus and Gram-negative bacilli. Fatal infections were more likely to occur in patients with a prior history of treatment with pulse methylprednisolone and in patients with more active LN, as evidenced by the higher proteinuria and serum creatinine levels and lower hemoglobin and lymphocyte counts in this group than in patients with non-fatal infections. Multivariate analysis indicated that factors associated with fatal infection were prior treatment with pulse methylprednisolone [odds ratio (OR) 11.2, 95% confidence interval (CI) 1.9-61.0], renal failure (OR 5.9, 95% CI 1.0-34.8), and fungal infection (OR 23.9, 95% CI 1.9-298.2). Cases of active LN treated with IVCY and pulse methylprednisolone who later develop severe infection that fails to respond to antibiotics should be carefully investigated for fungal infection.

Acute renal failure following wasp sting in children.

The medical records of patients admitted between 1985 and 2007 with wasp stings were retrospectively analyzed. Among the 45 children, seven developed acute renal failure. Classical clinical and laboratory data pointed to hemolysis and rhabdomyolysis as the underlying pathophysiology. All patients had hyponatremia and hyperkalemia as well as metabolic acidosis. Six patients had anemia. Five patients were oliguric for 9 to 15 days. Maximum serum creatinine was 4.0 to 11.9 mg/dl. Peritoneal dialysis was performed for 3 to 15 days. One patient died due to hyperkalemia, the remaining ones recovered completely. This paper wants to remind pediatricians to watch for acute renal failure in children with wasp stings.

Characteristics of primary vesico-ureteral reflux in Thai children.

BACKGROUND: The purpose of the present paper was to evaluate the clinical features of primary vesico-ureteral reflux (VUR) in Thai children. METHODS: Children with primary VUR attending in the Nephrology Division, Department of Pediatrics, Prince of Songkla University between 1987-2002 were studied. RESULTS: Sixty-five girls and 60 boys with primary VUR were evaluated. Age of diagnosis was significantly younger in boys than girls (median 0.6 and 2.2 years respectively, P < 0.001). In 73% of boys and 34% of girls VUR diagnosis was made in the first year of life. Hydronephrosis was found in 22% of boys and 8% of girls (P = 0.004). Five per cent of children who had VUR grades I-III had hydronephrosis (6/121). Only children who had VUR grades IV and V had significant hydronephrosis: 33% (14/42) and 53% (10/19), respectively. Bilateral VUR was 60% overall and was significantly more common in boys (70% vs 40% P < 0.028), found in grades I-V at 33%, 61%, 60%, 65%, and 77%, respectively. Of 200 refluxing ureters, the total numbers of VUR grades I-V were 32, 37, 67, 45 and 19 respectively. VUR grade was significantly different by age (P = 0.014) but not by left-right side or sex. CONCLUSION: Primary VUR occurs equally in boys and girls, but in boys at a younger age. Bilateral VUR and hydronephrosis were significantly more common in boys, and VUR in boys was more severe. But hydronephrosis is a poor indicator for VUR screening even in high-grade VUR.

Childhood chronic kidney disease in a developing country.

We have retrospectively reviewed the records of children aged >1 month to 16 years who had been referred to the Department of Pediatrics of Prince of Songkla University's Faculty of Medicine, a tertiary referral center in Thailand, between 1982 and 2005 and subsequently diagnosed with chronic kidney disease (CKD). Our aim was to evaluate the prevalence and etiology of CKD in southern Thailand. There were 101 cases of CKD, with one case each diagnosed in 1988, 1989 and 1993, respectively, and 98 cases diagnosed between 1994 and 2005. These latter cases were divided into two 6-year periods: an early period (1994-1999), with 32 cases, and a later period (2000-2005), with 66 cases. The majority of this pediatric population with CKD were male (62/101, 61.4%). The etiologies of CKD were 35 cases of chronic glomerulonephritis (CGN) (34.7%), 29 of genitourinary tract (GU) anomalies (28.7%), nine of systemic lupus erythematosus (SLE) (8.9%), four malignancies (4.0%), four miscellaneous (4.0%) and 19 of unknown causes (18.8%). The patients were divided into age groups of <2 years (20 CKD patients), 2-6 years (15), >6-10 years (22), >10-13 years (20) and >13 years (24). The etiologies of CKD were significantly different in each age group, with GU anomalies and glomerulonephritis being the major causes of CKD in children aged 6 years (40/65, 61.5%), respectively. In conclusion, the incidence of CKD in our university hospital situation was not rare, with the prevalence doubling during the past 6 years, and the etiologies varying by age group.

Primary vesicoureteral reflux mediated renal scarring after urinary tract infection in Thai children.

AIM: To evaluate the association between primary vesicoureteral reflux (VUR) and renal scarring in children using 99 m Technetium-labelled dimercaptosuccinic acid (DMSA). METHODS: Children attending at Songklanagarind Hospital from 1987 to 2002 were evaluated. RESULTS: Ages at diagnosis of VUR in 46 boys and 52 girls were 1.1+/-1.6 and 2.9+/-2.5 years, median 0.6 and 2.3 years, respectively (P<0.001). DMSA scans were performed at 4.1+/-3.6 years. Renal parenchymal damage was detected in 34 kidneys (22%) of 154 demonstrated refluxing ureters, and one kidney (2%) of 42 non-refluxing ureters (P=0.002). Of 79 refluxing ureters in boys and 75 refluxing ureters in girls, there were 25 and nine renal scars, respectively (32% and 12%, P=0.003). Renal scars in VUR grades I-V were 11%, 7%, 12%, 44% and 64%, respectively (P<0.001). Multivariate analysis revealed that high grade VUR (P<0.001), age of diagnosis of VUR greater than 5 years (P=0.001), and male gender (P=0.002) were the most significant risk factors for renal scarring. CONCLUSION: High-grade VUR, age of diagnosis of VUR greater than 5 years and male gender were the most significant risk factors for renal scarring.

Outcome of conservative treatment of primary vesicoureteral reflux in 87 Thai children in a single center.

AIM: To evaluate the outcome of primary vesicoureteral reflux (VUR) using conservative treatment. METHODS: Eighty-seven children with primary VUR who had been treated with a conservative medical regimen and monitored through a yearly cystogram were recruited for the study. The study was conducted at the Pediatric Nephrology Clinic in Songklanagarind Hospital, the major tertiary care center in southern Thailand. Statistical analyses using Kaplan-Meier survival curves, chi-squared test, Fisher's exact test and multivariate analysis with Cox regression were performed. RESULTS: The study group consisted of 41 boys and 46 girls, with a total of 133 VUR. The age of the boys was significantly lower than that of the girls (P < 0.001). Resolution of the low grades (grades I-III) of VUR was significantly more frequent than that of the high grades (grades IV-V) (68/95, 72%vs 14/38, 37%; P < 0.001). Using the Kaplan-Meier survival analysis and log-rank test, the resolutions of VUR in boys versus girls, and age <1 years versus >or=1 years were not significantly different (P = 0.2252 and 0.4756, respectively). Low-grade VUR and unilateral VUR had significantly higher probabilities of resolution than high-grade VUR and bilateral VUR, respectively (P = 0.0041 and 0.0467, respectively). Multivariate Cox regression analysis indicated that among low-grade VUR, boys and unilateral VUR had significantly higher probabilities of resolution. Among the high-grade VUR, neither sex nor laterality had a significant effect on the probabilities of VUR resolution. CONCLUSION: This study offers more evidence that children with low-grade VUR have a higher chance of reflux resolution if they are boys and have only unilateral VUR. There is still no good guide for resolution of reflux in children with high-grade VUR.