Emerging progressive atypical acute kidney injury in young children linked to ethylene glycol and diethylene glycol intoxication.

BACKGROUND: There had been a sudden surge of unusually severe and rapidly progressing acute kidney injury (AKI) incidence in Indonesia since August 2022 which did not correspond to the rise of COVID-19 incidence. We suspected this was related to ethylene glycol (EG) and diethylene glycol (DEG) intoxication. This study is aimed at describing the clinical and laboratory characteristics of AKI related to D(EG) intoxication in order to spread awareness of the possibility of intoxication in cases of rapidly progressing AKI with unknown etiology. METHODS: We conducted a cross-sectional study by collecting secondary data from the pediatric AKI registry at a national referral hospital in Jakarta, Indonesia. Data on children admitted from January to November 2022 with diagnosis of stage 3 AKI based on KDIGO criteria were included. Data regarding demographics, symptoms prior to anuria, laboratory results, infection panel including COVID-19 status, treatment administered, and mortality were analyzed. RESULTS: Sixteen patients tested positive for EG and DEG, all with history of consuming syrup-based medications. High anion gap metabolic acidosis was observed in majority of patients with mean pH 7.33 ± 0.07 and mean anion gap 15.6 ± 7.8 mEq/L. No patient had high osmolal gap (mean osmolal gap 3.46 ± 4.68). One deceased patient, who had kidney biopsy performed, showed severe damage and calcium oxalate crystals in the kidney tissue. Mortality was recorded in six patients (37.5%). CONCLUSION: Careful history taking of patient's clinical course, including consumption of syrup-based medications and laboratory findings, might aid clinicians to establish a working diagnosis of D(EG) intoxication without needing to wait for blood toxicology test. Early diagnosis and therapy are crucial to prevent substantial mortality.

Role of dipstick albuminuria in progression of paediatric chronic kidney disease.

OBJECTIVE: Renal function of patients with chronic kidney disease (CKD) is typically evaluated by detecting proteinuria because it is a major predictor of CKD progression. In paediatric patients with CKD, urine albumin-to-creatinine ratio (ACR) is used to detect CKD progression, which is similar to urine protein-to-creatinine ratio (PCR). However, facilities for evaluation of urine ACR and urine PCR may not be widely available. To date, this is the first study that investigated the predictive value of baseline dipstick albuminuria for 1-year and 3-year CKD progression in Indonesian children. We assessed the association between baseline level of dipstick albuminuria and CKD progression in paediatric patients. METHODS: This retrospective cohort study was conducted at the Cipto Mangunkusumo Hospital (CMH) involving 43 children with CKD between 2016 and 2019. The patients were followed up for 1 year and 3 years after enrolment. Risk ratios (RR) for 1-year and 3-year CKD progression were calculated using Fisher's exact test. RESULTS: The RR for 1-year CKD progression in children with baseline dipstick albuminuria <2+ was 2.16 (95% CI: 1.13-4.14, p = 0.02), and the corresponding RR for 3-year CKD progression in these children was 1.70 (95% CI: 0.73-3.97, p=0.21). CONCLUSIONS: Dipstick albuminuria was not associated with 1-year and 3-year CKD progression in children.

The Proportion of Bifidobacterium and Escherichia coli in Colon of Children with Recurrent Urinary Tract Infection.

Recurrent urinary tract infection (UTI) in children is a well-known risk factor of chronic kidney disease. Periurethral area is normally inhabited by non-pathogenic flora, such as Bifidobacterium sp., and pathogenic flora from gastrointestinal tract, such as Escherichia coli (E. coli), which can cause UTI. Dysbiosis between pathogenic and non-pathogenic bacteria leads to infections, but studies regarding dysbiosis and recurrent UTI have not yet been documented. To estimate the proportional differences between gastrointestinal E. coli and Bifidobacterium sp. in children with recurrent UTI, a cross-sectional study was conducted in children from age six months to <18 years old diagnosed with recurrent UTI in Dr. Cipto Mangunkusumo Hospital. Healthy children matched in gender and age were recruited as control group. Stool samples were obtained from all the children in the two groups. Stool DNA was extracted using real-time polymerized chain reaction method to count E. coli and Bifidobacterium sp. proportion. Children with recurrent UTI had significantly higher proportion of E. coli compared to control group (10.97 vs. 4.74; P = 0.014) and lower proportion of Bifidobacterium sp. (6.54 vs. 9.33; P = 0.594). In children with recurrent UTI group, E. coli proportion was found higher than Bifidobacterium sp. although not statistically significant (10.97 vs. 6.54; P = 0.819). In healthy controls, Bifidobacterium sp. proportion was significantly higher than E. coli (4.74 vs. 9.33; P = 0.021). The total amount of E. coli (996,004 vs. 1,099,271; P = 0.798) and Bifidobacterium sp. (835,921 vs. 1,196,991; P = 0.711) were higher in secondary UTI compared to the simple UTI. Proportion of E. coli is higher in children with recurrent UTI than in healthy children. The proportion of E. coli is higher than Bifidobacterium sp in the colon of children with recurrent UTI.

Low-Dose Maintenance Intravenous Iron Therapy Can Prevent Anemia in Children with End-Stage Renal Disease Undergoing Chronic Hemodialysis.

Iron deficiency anemia is common in children with end-stage renal disease (ESRD) on long-term hemodialysis receiving erythropoiesis-stimulating agents. One approach to maintain the iron profile and hemoglobin levels is maintenance therapy with regular low doses of intravenous (IV) iron after initial iron repletion therapy; however, evidence for the benefits of this approach is lacking. This study evaluated the effect of IV iron maintenance therapy on anemia in children on regular hemodialysis. This retrospective cohort study included 41 pediatric ESRD patients with normal hemoglobin and iron status who underwent regular hemodialysis at the Pediatric Dialysis Unit of Cipto Mangunkusumo Hospital, Indonesia, between January 2015 and April 2019. Among these, 21 received IV iron maintenance therapy with two doses of 2 mg/kg of IV iron sucrose every 2 weeks (the treatment group) and 20 did not (the comparison group). Changes in hemoglobin and transferrin saturation were assessed after 6 weeks of observation and compared between the two groups. There was a significant reduction in the mean hemoglobin level compared with the baseline level in the comparison group (21 g/L; 95% CI, 9.3-33 g/L; p=0.001) but not in the treatment group (0.7 g/L; 95% CI, -6.6-8 g/L; p=0.84). The risk of anemia was lower in the treatment group (relative risk = 0.42; 95% CI, 0.22-0.79; p=0.003). Although majority of the patients had high baseline ferritin level, this study indicates that in our setting, ferritin may not be a reliable parameter to review the iron status, as it can be affected by chronic inflammation. Hence, the decision to start IV iron maintenance therapy in patients with hyperferritinemia should consider the patient's clinical condition and morbidity. To conclude, the coadministration of IV iron maintenance therapy is beneficial for maintaining hemoglobin levels and preventing anemia in children with ESRD who are undergoing regular hemodialysis, have achieved the target hemoglobin levels, and have normal iron status.

Effective Management of Peritoneal Dialysis-Associated Hydrothorax in a Child: A Case Report.

Peritoneal dialysis (PD) confers many advantages, including a better quality of life for children with end-stage renal disease; however, the procedure is associated with several complications, including pleuroperitoneal leaks. Here, we report an unusual case of hydrothorax caused by long-term PD in a child, which was further complicated by pneumonia. A 9-year-old boy who had received CAPD for 22 months presented with dyspnea, swelling, and increased body weight. Chest tube drainage yielded 500 mL of transudative fluid. Computed tomography peritoneography revealed increased outflow from the peritoneum to the pleural cavity. PD was suspended, and hemodialysis (HD) was initiated. Video-assisted thoracoscopic surgery was performed; however, because the patient had pneumonia during hospitalization, pleural adhesions with a septated appearance occurred. This resulted in difficulties identifying pleuroperitoneal fistula (PPF). Right pleural effusion resolved following pleurodesis using bleomycin. Regular HD was performed for 10 weeks, and PD was subsequently reinitiated. There was no recurrence of hydrothorax during long-term follow-up. We suspect that the underlying mechanism of hydrothorax in our patient was associated with a PPF that formed either due to a congenital diaphragmatic defect or an acquired defect, resulting in dialysate leakage. Our case demonstrates that a temporary switch from PD to HD, accompanied by pleurodesis, may help resolve hydrothorax that occurs as a complication of long-term PD.

Quality of Life in Chronic Kidney disease children using assessment Pediatric Quality Of Life Inventory™.

Chronic kidney disease (CKD) is still a serious health problem in children with increasing morbidity and affecting children's quality of life (QoL). The prevalence of children with CKD worldwide is approximately 82 cases/year/1 million children. From the Indonesian Basic Health Survey 2013, the prevalence of patients with CKD aged ≥15 years in Indonesia was 0.2%. To assess the QoL in children with CKD as well as its relationship with duration of diagnosis, severity, and related demographic factors, a cross-sectional analytic study was conducted. Individuals were recruited from July 2016 to May 2017 through consecutive sampling. CKD children aged 2-18 years who treated with conservative therapy and hemodialysis were included. Patients and their parents were asked to fill out the PedsQL™ generic score scale version 4.0 questionnaire. A total of 112 children were recruited, and QoL was assessed from parental reports (54.5%) and children's reports (56.3%). The school and emotional aspects were the lowest score parameters studied. Factor related to QoL children with CKD were length of diagnosis >60 months (P = 0.004), female (P = 0.019), and middle school (P = 0.003). More than half of the children with CKD have disturbance of QoL in general from parental reports (54.5%) and children's reports (56.3%). Length of diagnosis >60 months, female, and middle school education were all related to the QoL children with CKD.