Divya Atri, O.P.Mishra, S.K.Singh, Z.Ali, Rajniti Prasad

NEP/01(O) SERUM LIPID PROFILE INCLUDING LIPOPROTEIN (A) LEVELS IN CHILDREN WITH IDIOPATHIC NEPHROTIC SYNDROME

Divya Atri, O.P.Mishra, S.K.Singh, Z.Ali, Rajniti Prasad

Departments of Pediatrics, Institute of Medical Sciences, Banaras Hindu University, Varanasi-221005.

Objective : To evaluate the lipid parameters including Lipoprotein (a) [ Lp(a)] in idiopathic nephrotic syndrome during active and remission phase of disease. Design : Prospective study : Pediatric Nephrology Clinic of a teaching hospital. Subjects : Twenty nine patients of idiopathic steroid responsive nephrotic syndrome, aged 2-10 years and 10 healthy age matched controls. Methods : Serum triglycerides (TG), cholesterol, high density lipoproteins (HDL), low density lipoproteins (LDL), very low density lipoproteins (VLDL) and Lp(a) levels were estimated in all the study subjects at presentation and could be repeated in 7 cases of remission, after 4 weeks of stoppage of therapy. Results : The mean serum TG, cholesterol, HDL, LDL, VLDL and Lp(a) levels were significantly raised in active nephrotic syndrome (ANS) and its sub-groups (15 first episode, 8- infrequent relapsers and 6- frequent relapsers) as compared to controls (P<0.001). The overall mean levels were 455.1%, 450.2%, 370%, 452.4%, 455.8% and 250.8% of normal in ANS cases, respectively, with all the values above 2 SD. No significant differences in the mean levels were found among different sub-groups of cases. During remission, the mean TG, cholesterol and VLDL showed significant reduction, but the levels were still significantly higher than controls. Although the mean LDL and Lp(a) levels showed significant reduction and became comparable to those of controls, but abnormal levels of LDL (>130mg/dl) and Lp(a) (>30mg/dl) persisted in 28.6% and 57.1% of cases, respectively in remission. The mean HDL value remained unaltered. The serum TG (r = - .5942, P <0.001), cholesterol (r = - .5856, P<0.001), HDL (r = - .4794, P<0.01), LDL (r = - 0.4411, P<0.05), and VLDL (r=-0.5942, P<.001) had significant negative correlations, while Lp(a) did not show any relationship with serum albumin in ANS patients. Conclusion : It is evident that lipid parameters including Lp(a) are raised during active phase of disease. The abnormalities persist even during remission. Thus, these patients require a long-term follow up for normalization of their levels and detection of complications, if any, related to atherogenesis and thrombosis.

NEP/02(P) URINARY TRACT INFECTION IN CHILDREN : MOST COMMON CLINICO BACTERIOLOGICAL PATTERN

K Ranganathan, VN Tripathi, RP Singh, GC Upadhyay

Department of Pediatrics and Microbiology,GSVM, Medical College, Kanpur

Objective : (1) To know about the age and sex pattern of children suffering from Urinary tract infection (UTI). (2) To know about common clinical presentation of urinary tract infection (UTI) in children. (2) To find out the causative organism responsible for urinary tract infection (UTI) in febrile children. Design: Prospective Hospital based study. Setting: Department of Pediatrics and Department of Microbiology, GSVM Medical College, KanpurMethods : A total of 350 cases of suspected UTI were studied out of which 308 cases were found to be bacteriologically positive. 196 cases had complaints pertaining to urinary tract infection and other 112 cases were indoor admissions for other diseases in which history was not suggestive of urinary tract infection but because of persistence of fever unexplained by ‘physical examination or any visible abnormality of urine or in presence of any predisposing factors, diagnosis of urinary tract infection was established by urine culture. RESULTS : It was found that maximum no. of urinary tract infection (UTI) cases were in children age group 1-5 yrs (51%) and minimum in 10-18 yrs (8%). Male patients were predominant in the age group 1-2 yrs were as girls were predominant in the age group 2 yrs onward as well as over all. UTI was diagnosed as an associated finding in 36.7% chief diseases being nephrotic syndrome and marasmus. Among general clinical symptoms fever was the commonest (86.6%). Other symptoms being pallor (53.4%), loose motion and vomiting. Most common urinary complaint was increased frequency (41%) followed by dysuria (27.2%). E. coli was the commonest cause in all age groups with relative higher percentage in lower age groups. Conclusion : UTI is a common possibility in febrile children. Maximum no. of cases occur in under 5 children. Boys have a slight predominance in infancy whereas girls are more commonly affected after infancy. Fever is the commonest general symptoms where as increased frequency is the commonest urinary complaint. E. coli is the commonest organism in all age groups being more frequent in lower age groups.

NEP/03(O) URINARY TRACT INFECTION IN MALNOURISHED CHILDREN

S. Manazir Ali, Aditya Dixit, Azra J. Ahmad, Mithlesh Agarwal

Dept. of Pediatrics, J. N. Medical College, AMU, Aligarh – 202002

Urinary tract infections in malnourished children are significantly higher than well nourished children which is attributed to suppression of quality of immune status of malnourished children and stagnation of urine in urinary tract due to transient hypokalaemia. It is further observed that urinary symptoms are masked in malnourished children. Hence this prospective case control study was carried out in the Department of Pediatrics in collaboration with the Department of Microbiology of Jawahar Lal Medical College, AMU. Aligarh with effect from May 2003 to April 2004 in order to estimate the prevalence of UTI and its association with severity of malnutrition. 125 children in the age group of 6 month to 5 years who were malnourished with a weight for age < 80% formed the study group while the children with weight for age > 80% served as controls. There was predominance of males over females with M: F ratio around 1.76: 1 and 1.8:1 in study and control groups respectively. Detailed history suggestive of UTI such as dysuria, frequency, abnormal stream of urine and enuresis was taken and thorough examination was done. Fresh urine was collected by aseptic manner in a sterile vial by suprapubic aspiration in children < 1 year. A clean catch & mid stream urine sample was collected in older children and immediately transported to Microbiology lab for inoculating 0.01ml over 5% sheep blood agar and Teepol lactose agar and incubated at 37 C for 24 hours aerobically. Then antibiotic sensitivity was done by using standard diffusion method. 11.2% of malnourished children had positive urine culture in the form of E. coli (71.4%), Citrobacter (14.2%), Enterococcus faecalis (7.1%) and Pseudomonas (7.1%), while among controls single urine culture positive of E. coli was found. E coli organism was sensitive to amikacin, ciprofloxacin, ofloxacin and norfloxacin while Pseudomonas and Enterococcus faecalis were sensitive to ceftazidime and co-trimoxazole respectively. Hence, in conclusion UTI in moderately and severely malnourished children is symptomless as compared to well nourished children and it demands a thorough urine analysis for chemical and culture in order to avoid fulminant septicaemia and renal impairment.

NEP/04(O) RISK FACTORS FOR RELAPSE IN CHILDHOOD STEROID SENSITIVE NEPHROTIC SYNDROME

Dakshayani B,Premalatha.R,H.M.Vishwanath Kumar,M.L.Siddaraju

Department of Pediatrics,Bangalore medical college,Bangalore-560001

Background: More than half the children with steroid sensitive nephrotic syndrome will have relapses. They require long term treatment with steroid and or cytotoxic agent and are at high risk for side effects. Therefore it is important to identify them early. Objectives: To determine the risk factors for relapse in childhood steroid sensitive nephrotic syndrome. Methods: Hospital based retrospective and prospective study was conducted from May-03 to Jan-05. 59 patients with steriod sensitive nephrotic syndrome were followed up for 1 – 1.5 years. Data for those patients who had onset of disease prior to study was collected from records and then were followed up prospectively. Ten variables were studied as possible risk factors. Pearson chisquare was used for categorical variables; student ‘t’ test or Wilcoxson rank test for means.Cox proportional hazard regression model was used to examine the independent effect of related risk factors on relapses. Results: 59 patients were enrolled who had 168 relapses. The mean age at onset was 3 years with a range of 1 – 13 years. Male female ratio was 1.94:1. Of all the patients 22% were non relapsers, 47% were infrequent relapsers and 30.3% were frequent relapsers and or steroid dependent. Age at onset, sex, serum albumin, duration of the remission period just before the most recent relapse, infections, duration of illness, did not influence subsequent relapse. More than 7 days to achieve remission during first episode, one or more relapses in first year, short duration of the first remission period were significantly assosciated with increased relapse rate. Levamisole significantly decreased relapse rate. Conclusion: Number of days to achieve remission during first episode, duration of the first remission period, frequency of relapses during first year can predict future relapses. These factors should be considered while starting alternative drugs,to counsel the patients,to follow them closely,to develop better treatment protocols.

NEP/05(P) ROLE OF LEVAMISOLE IN STEROID SENSITIVE NAPHROTIC SYNDROME CHILDREN WITH FREQUENT RELAPSES AND STEROID DEPENDENCY

Balakrishnan.R., R.Premlatha., Siddaraju.M.L.

Vanivilas Childrens Hospital, Bangalore Medical College, Bangalore-560002

Introduction: Steroid dependency and frequent relapses are common with steroid sensitive nephrotic syndrome. Among the different drugs used in this situation, Levamisole is the most effective, least toxic and least expensive. Objectives: To study the effectiveness of Levamisole in reducing relapses and steroid dose in children with frequent relapsing and steroid dependent nephrotic syndrome. Design:Hospital based prospective study. Settings and methods: All children with frequent relapsing and steroid dependent nephrotic syndrome registered and attending the Nephrology clinic in Vanivilas childrens Hospital, Bangalore were included as subjects. Children treated with Levamisole for less than 6 months and who were pretreated with other alkylating agents like Cyclophosphamide were excluded from the study. Study was conducted from the period of march 2003 to august 2005. Levamisole was administered in the dose of 2-3 mg/kg/48 hrs after inducing remission with steroids, to the subjects included in the study. Subjects were followed up every 2 weeks for a period from 6 months to 2.5 years to watch for relapse of the disease and attempt was made to reduce the dose of steroids by 5mg once in every 4 weeks. Complete Blood Count was done once in 3 months to ascertain side effect of the drug. Results: Fifteen children were treated with Levamisole. The age range was from 6 months to 8 years and the mean age was 2.7 years. Mean duration of the therapy was 13 months and the range was from 8 months to 2 years. Only 12 of the 15 recruited children could complete the study, 7 of these were frequent relapsers and 5 were steroid dependent. After therapy, 5 (71.4%) out of 7 frequent relapsers and 2 (40%) out of 5 steroid dependent children did not have any further relapse. Frequency of relapse decreased from 4.38 relapses / year to 0.36 relapse / year (p<0.05) in frequent relapsers and from 2.72 / year to 0.92 / year (p<0.05) in steroid dependent children. The mean dose of steroid on which the child was dependent reduced from 1.56mg/kg/48 hrs to 0.48 mg/kg/48 hrs (p <0.05). The only side effect noted was trtansient leukopenia in 1 patient which did not neccesitated withdrawal of the drug for about 4 weeks. Conclusion: Levamisole is an effective and safe drug for children with frequent relapsing and steroid dependent nephrotic syndrome in maintaining remission and acting as a steroid sparing agent.

NEP/06(O) VOIDING DISORDERS PRESENTING AS RECURRENT URINARY TRACT INFECTIONS

H Ravi Ramamurthy, Madhuri Kanitkar, M K Behera

Command Hospital, Wanowrie Road, Pune

Introduction: Problems related to bladder manifest as recurrent urinary tract infections (UTIs), obvious incontinence, or as nocturnal enuresis with daytime symptoms. Aim: To determine the underlying bladder dysfunction in children presenting with recurrent UTIs and to compare them with the bladder dysfunction in children undergoing bladder evaluation for any other cause. Material & Methods: The data of 70 consecutive children presenting with complaints suggestive of voiding disorders evaluated at the bladder clinic of a tertiary level hospital were prospectively studied. All children were evaluated as per a proforma by history taking, clinical examination, non- invasive urodynamics (frequency volume charting + Ultrasonography) and invasive urodynamics when indicated. They were divided into two groups. Group I comprised of children presenting with recurrent UTIs and Group II comprised of those with other symptoms suggestive of voiding disorders. The data obtained was analyzed by Fischer Exact test (EPI 6) to determine the statistical significance. Results: Group I had 27 children (Average age 6.29 years, Male: Female ratio 1:1.5) and Group II had 43 children (Average age 6.74 years, Male: Female ratio1.3:1). The Bladder abnormality seen in Group I vs Group II were Detrusor instability in 14 vs 32 (p>0.05), Dysfunctional Voiding in 7 vs 1(p<0.05), Hinman’s Bladder in 2 vs nil and Others in 4 vs 10 respectively. The diagnosis of bladder abnormality was done by invasive urodynamics for 9 in Group I and for 2 in Group II (p=0.002). Conclusion: 1. The commonest bladder abnormality is detrusor instability, both in the children who present with UTIs and in those with other urinary problem. 2. The occurrence of dysfunctional voiding as the underlying bladder dysfunction is significantly higher in the children evaluated for recurrent UTIs than those evaluated for other urinary problems.

NEP/07(O) CLINICAL PROFILE OF ACUTE RENAL FAILURE (ARF) IN NEONATES

Pravakar Mishra, Arun Agrawalla, Suresh K Panda, J.N. Behera, A.K Mohanty

SVP Post-Graduate Institute of Pediatrics and SCB Medical College, Cuttack, Orissa.

Introduction: Acute Renal Failure (ARF) is a serious and potentially fatal illness in neonates. Objective: To study the incidence, clinical profile and outcome of ARF in neonates. Design: Prospective study from July 2002 to June 2005. Setting: Special Care Neonatal Unit (SCNU) of SCB Medical College, Cuttack and Neonatal Ward of SVP PG Institute of Pediatrics, Cuttack, Orissa. Subject & methods: 80 neonates (birth to 28 days) with features of ARF like anuria/oliguria (urine output <1 ml/kg/hr) and/or azotemia with blood urea above 40 mg/dl and/or serum creatinine >1.5 mg/dl were taken up for this study. All cases were subjected to thorough history and clinical examination. The renal parameters considered were serum urea, creatinine, Na+ & K+ and urinary creatinine & Na+. Prerenal and renal causes of ARF were found out by using urinary indices like fractional excretion of Na+ (FeNa), renal failure index (RFI) and response to fluid challenge after ruling out obstructive uropathy. Results: Incidence of ARF was 3.4% with M:F ratio 2:1. 26(32.5%) cases were preterm and 48(60%) cases were low birth weight (LBW). Majority (70%) were home delivered. Most cases 63(78.7%) presented within first 5 days of birth. Prerenal, renal and postrenal causes were found in 57(71.3%), 19(23.7%) and 4(5%) of cases respectively. 55(68.7%) cases were oliguric and 25(31.3%) cases were non-oliguric ARF. The major causes of ARF were Perinatal Asphyxia 44(55%), Septicemia 24(30%), Congenital anomalies and Diarrhea 5(6.5%) each. Cases were managed by fluid challenge, diuretics, dopamine infusion and peritoneal dialysis as per the merit of the case. Peritoneal dialysis could be done in 5 cases out of which only 2(40%) survived. On one year follow up unilateral/bilateral renal scarring was seen in 26(83.8%) cases. Overall mortality was 49(61.3%) with only 31(38.7%) survivors. Conclusion: Perinatal asphyxia and septicemia were the major causes of ARF. Most cases were of low birth weight. Majority of cases were prerenal failure and oliguric type and majority presented within first five days of birth. High index of suspicion and prompt management including peritoneal dialysis can improve outcome in neonatal ARF.