Renal venous thrombosis in children: changes in management.

Renal venous thrombosis, a clotting process that originates in the venous radicles and progresses into the main renal vein and vena cava, predominantly affects newborn infants. It may be manifest in one or both kidneys and follow maternal diabetes, diarrhea and dehydration, congenital heart disease, acute blood loss, sepsis, asphyxia, and shock. The most common signs include gross hematuria, enlarged palpable kidneys, and thrombocytopenia. Evaluation should include ultrasonography of the kidneys (demonstrating renal enlargement with disruption of the normal echo pattern), computed tomography, and renal isotope scanning. The initial treatment is supportive. Surgical intervention is not indicated in the acute phase except in the rare instance of bilateral disease. Anticoagulant therapy is still controversial. Late sequelae include impairment of renal function, shrunken hypoplastic kidney, arterial hypertension, and tubular defects.

Chronic progressive renal failure. Rate of progression monitored by change of serum creatinine concentration.

The rise of serum creatinine levels during were renal failure progressing to end-stage renal disease was studied in 30 children. In 20 patients the rise was a steady one and followed a mathematical model, best expressed by the regression line calculated from reciprocal values. Ten patients had widely fluctuating values that did not fit any of the available mathematical models; however, in three patients, the curve had two slopes. The initially slow rate of progression changed to a more rapid, steady rise when a creatinine level of 2 to 3 mg/dL was reached. Therefore, in 23 of 30 patients, the time at which a serum creatinine values of 10 mg/dL would be reached could be predicted with acceptable accuracy based on this calculation or using a graphic plot. In the terminal phase of renal failure, the serum creatinine value progressed from 7 to 10 mg/dL in less than four months in 80% of the cases.

Zinc changes after renal allotransplantation.

In 72 patients the plasma zinc concentration and the urinary zinc excretion were studied immediately after renal allotransplantation and during a 7 1/2-year follow-up period. The plasma zinc concentration was below that of healthy control subjects during the first three weeks after transplantation (mean 39 microgram/dl) and returned to the control level within the subsequent four weeks. The urinary zinc excretion and correspondingly the urinary zinc/creatinine ratio (> 1.0 microgram/mg) were increased during the first week after transplantation. During the remainder of the observation period, both plasma and urinary zinc were within the control range. The observed changes parallel those reported after major operations. We could not detect any influence exerted by acute or chronic rejection, serious infection, or corticosteroid therapy.

Changes in zinc metabolism during the course of the nephrotic syndrome.

The plasma zinc concentration and quantitative urinary zinc excretion were studied in 105 pediatric patients with the nephrotic syndrome or nephritis-nephrosis. The plasma level was decreased to a mean value of 51.7 microgram/dL in patients with the nephrotic syndrome (controls, 85 microgram/dL). The rate of urinary zinc excretion was not different from that of the controls, with the exception of patients whose disease was in the polyuric phase of beginning remission where it was fivefold higher and those who had achieved a long-lasting remission of the disease. Since about two thirds of the plasma zinc is bound to albumin, an unchanged zinc-albumin ratio would reflect an equal zinc and albumin loss. The ratio, however, was increased twofold and thus does not adequately explain the hypozincemia. The low hair level of 86 microgram/g may suggest a more profoundly disturbed zinc metabolism than originally thought.

[Tolerance studies of an intravenous fat emulsion (FE-S15) with beagle dogs]. / Untersuchungen zur Verträglichkeit einer intravenösen Fettemulsion (FE-S15) bei Beagle-Hunden.

The potential toxicity of FE-S15, a soybean oil fat emulsion used in parenteral nutrition, was studied in dogs. Forty pure bred beagles, divided into two experimental groups (FE-S15 at 9 and 4 gm/kg BW/day) and two corresponding control groups (receiving Dextrose Ringer's Solution) were given daily infusions for 28 days via a central venous catheter. When compared with control groups no significant weight loss was observed in either experimental group; the food intake decreased only in animals receiving fat in high doses. Hemoglobin and hematocrit decreased in all groups, the greatest fall observed in the group receiving high dose fat infusion was the hematocrit decline from 43.9% to 31%. This decrease was significantly different from the control only during one observation period. The total serum lipids, triglyceride and phospholipid concentrations of the animals receiving fat in high doses increased 3-4 times in comparison to that of the control group; cholesterol increased 5 times. The serum protein level fell from 6.5 to 5.1 gm/dl in animals receiving 9 gm/kg BW/day while animals receiving 4 gm/kg BW/day had a significant increase to 8.4 gm/dl. Except for an overall decreased activity clinical sign such as lethargy, loss of appetite, vomiting, and diarrhea were infrequent and equally observed in experimental and control animals. The post mortem examination did not reveal changes that must be attributed to the administered fat. It is concluded that the fat emulsion FE-S15 is fairly well tolerated in dogs at a potentially toxic level.

Studies of the toxicity of an intravenous fat emulsion. i. Hematologic changes and survival after administration of a soybean oil (FE-S15) in beagles.

The potential toxicity of FE-S15 (B. Braun-Melsungen), a soybean-oil fat emulsion used in parenteral nutrition, was studied in dogs. Forty pure-bred beagles, in two experimental groups (FE-S15 at 9 and 4 g/kg/day) and two corresponding control groups (receiving Dextrose-Ringer's solution), were given daily infusions for 28 days via a central venous catheter. Vital signs and hematologic, biochemical, and bacteriologic changes were monitored closely. When compared with control groups, no significant weight loss was observed in either group; the food intake decreased only in animals receiving fat in high doses. Hemoglobin and hematocrit decreased in all groups during infusion, the greatest fall observed in the group receiving high-dose fat infusion where the hematocrit declined from 45.5% to 31.7%. This decrease was significantly different from the controls only during one observation period. Clinical signs, such as lethargy, vomiting, diarrhea, loss of appetite and fever were observed infrequently in both experimental and control animals, more often in those treated with high-dose fat infusion. It appears that the fat emulsion FE-S15 causes only minor side effects but otherwise is well tolerated in dogs at a potentially toxic level.

Studies of the toxicity of an intravenous fat emulsion. II. Blood chemical changes after administration of a soybean oil (FE-S15) in beagles.

Biochemical changes were monitored during fat infusion as part of an evaluation of the toxicity that accompanies the intravenous administration of a new soybean oil emulsion in dogs. Beagles were given FE-S15 at 9 and 4 g/kg/day for 28 days via a central venous catheter. The total serum lipid, triglyceride, and phospholipid concentrations of the animals receiving fat in high doses increased 3 to 4 times in comparison to that of the control group; cholesterol increased 5 times. The rise of serum lipid fractions was proportionally smaller in animals receiving the low dose fat infusion. All values returned to the control range 2 wks after termination of the infusion. The serum protein level fell from 6.5 to 5.1 g/dl in animals given 9 g/kg/day fat while animals receiving 4 g/kg/day had a significant increase to 8.4 g/dl (day 27). In comparison with the control groups, the animals receiving low dose fat infusion also had a significant rise in serum albumin and, to a lesser degree, in alpha and beta globulins. A rise in alkaline phosphatase activity was observed in all dogs receiving fat infusion, but was significantly different from the controls only in animals on high dose fat infusion. None of the other monitored biochemical serum values were affected by the administered fat and there was no evidence of disturbance in liver function.

Detection and elimination of contaminations interfering with the determination of zinc in plasma.

We undertook detailed examination of the practices and procedures involved in the analysis of serum for zinc by atomic absorption spectrophotometry, to identify possible sources of zinc contamination. Some degree of contamination was found in almost all steps of the procedure. These findings are presented and alternative materials and procedures are described that significantly decrease or eliminate contamination from extraneous zinc. The plasma of 76 normal adults was analyzed by the revised procedure, and a lower mean value was obtained than has been previously reported.

Renal failure during the first year of life.

All cases of persistent renal failure in infants less than 1 year of age were reviewed to determine whether the prognosis has improved equally for infants as for adults. During a ten-year period, 52 infants were treated by applying uniform therapy; 28, more than half, were less than 4 weeks old. All cases were separated into two groups; 19 infants without and 33 infants with congenital renal or urinary tract anomalies. In 20 patients of the latter group, additional serious anomalies of other organs were present. The age distribution was strikingly different: in 18 of 21 infants, renal anomalies were present, as diagnosed on the first day of life. In contrast, only 3 of 11 infants, 4 to 12 months old, had urinary tract anomalies. In infants without renal anomalies, renal failure was caused by hypotension or shock in 10 of 19 cases, by pyelonephritis or sepsis un 6 of 19. Of this group, eight infants (42%) recovered completely, nine (47%) died. Death occurred within one to two days of hospitalization in all but three cases, caused by shock or sepsis. In this group medical problems that are amenable to therapy have caused either renal failure or contributed to the infant's death. In infants with renal or urinary tract anomalies, renal failure was caused by renal dysplasia or agenesis in 16 of 33 infants, by urinary tract obstruction in 12 of 33. Only three patients (9%) recovered, all older than 4 months, 20 (61%) died, and 10 are living with signs of chronic renal failure. Death usually occurred within one week of hospitalization and, in 16 of 20, it was caused by renal failure and multiple additional anomalies. The multiplicity and complexity of the congenital anomalies in most instances precluded effective, lifesaving therapy. Renal failure in infants is still a serious disease accompained by a high mortality rate in which therapeutic possibilities are limited. No improvement in prognosis can be expected in the near future. Pediatrics, 59:987-994, 1977, RENAL FAILURE, CONGENITAL RENAL ANOMALIES, INFANT, ISCHEMIC RENAL DAMAGE.

Polyarteritis in children.

Polyarteritis was diagnosed in three girls, 9 to 10 years old, by kidney and skin biopsies. They were treated with a combination of prednisone (1.5 to 2 mg/kg) and cyclophosphamide (2 mg/kg) for up to 12 months. The illness was severe in all three, complicated by hypertension, seizures, pulmonary infiltrates, renal failure, or hallucinations. All three patients are alive and well with no or minimal residual symptoms two to three years after therapy was discontinued. The treatment with corticosteroids or with a combination of steroids and immunosuppressive drugs seems to improve the prognosis of polyarteritis considerably.