Incidence and etiology of acute kidney injury in children admitted to PICU using pRIFLE criteria

Acute Kidney Injury (AKI) has become a major global health care challenge with an estimated 13.3 million cases per year leading to an estimated mortality of 1.7 million deaths per year globally. Increasing prevalence of AKI is strongly associated with increased early and long term patient morbidity and mortality. According to recent meta-analysis conducted by Paweena et al the pooled incidence rate of AKI was 33.7% (95% CI, 26.9 to 41.3) and AKI-associated mortality rates was 13.8% in children (95% CI, 8.8 to 21.0) .

“0 by25” is an ambitious initiative of International Society of Nephrology which aims to eliminate preventable deaths from Acute Kidney Injury worldwide by 2025. This initiative emphasizes the magnitude of the problem, the global concern about AKI and its endeavour to eliminate mortality and morbidity due to AKI

Acute kidney injury previously called acute renal failure is characterized by a reversible increase in the blood concentration of creatinine and nitrogenous waste products and by the inability of the kidney to appropriately regulate fluid and electrolyte homeostasis . If left untreated, the condition has a high risk of multiple organ failure and potentially death.

Patients who suffer from AKI may have subsequent renal dysfunction after original injury. Children are more susceptible for this dysfunction .

For a long time there was lack of consensus on definition of AKI. In 2005, the first consensus definition of AKI for the adult population, based on the RIFLE (Risk, Injury, Failure, Loss of function, End stage renal disease) criteria, was proposed by the Acute Dialysis Quality Initiative Group (ADQI)  The definition was later modified and evaluated in critically ill pediatric patients and termed pRIFLE (Pediatric RIFLE) criteria.

 The pRIFLE criteria differs from RIFLE criteria, in that a) Only decrease in estimated creatinine clearance (eCrCL), and not the change in glomerular filtration rate, is used to determine grading b) The eCrCl is estimated using the Schwartz formula, which incorporates the height and serum creatinine level of the patient, and an age adjusted constant c) pRIFLE incorporates a longer duration of urine output than in adult RIFLE classification.

The spectrum and burden of AKI in developing countries may be different from that of developed countries .The patients from developing countries are younger, infection associated AKI is more common and a significant proportion may have already developed AKI at the time of hospitalization. In addition, resource limitations in managing children who require renal replacement therapy add to the burden .

Spontaneous Remission in Congenital Leukemia AML-M1 with Pericardial Effusion

Congenital leukemia is a very rare malignancy of childhood with poor prognosis. The incidence is nearly 1 in 5 million live births. Although mortality is high due to aggressive course and complications of the treatment, the two-year survival rate is 23% [2]. The etiology is unknown but it is assumed that genetic factors, environmental factors, viral infections and immune deficiencies may be responsible. Among many clinical symptoms and signs hepatosplenomegaly, petechia, eccyhmoses and nodular skin lesions may present since birth. Against childhood, in neonatal period two thirds of the leukemia are originated from myeloid cells. The most defined types are AML M4 and M5. We report a 23 days old girl who was diagnosed as AML M1 with a rare complication of pericardial effusion.

Case Report

Peripheral blood smear revealed atypical cells so he was referred to our hospital with pre-diagnosis of congenital leukemia. At admission she was 23-days-old, 3460 grams in weight, 50.5 cm in height, 35 cm in head circumference. Her physical examination revealed phenotypically normal girl with pallor, periorbital hyperemia and edema, ecchymotic lesions and edema on bilateral hands and feet, nearly 2 cm diameters mobile and solid nodules over the trunk and anterior surfaces of the thighs. Liver was 4 cm and spleen was 3 cm palpable below costal margin and 2/6 systolic murmur was heard. Laboratory evaluations were as following: leucocyte count 40410/mm3, hemoglobin 9.2 gr/dl, hematocrit 27.4%, platelet count 175000/mm3, LDH 2281 U/L, GGT 290 U/L. On peripheral blood smear there were 20% blasts. 

A Case of Prenatal Presentation with Double Aortic Arch

Introduction

Left and right aortic arch refers to the position of the aortic arch in relation to the trachea. Normal embryological development of the arch is from the primitive pharyngeal arch system. The normal left aortic arch (LAA), descending on the left side of the trachea, is formed from the left fourth arch and the left dorsal aorta with regression of a segment of the embryological right aortic arch (RAA).

Double aortic arch (DAA) is a form of vascular ring in which the trachea and esophagus are completely encircled by the RAA and LAA. This condition causes compression of the trachea and esophagus, leading to various symptoms, including respiratory obstruction, dysphagia, chronic wheezing, vomiting, and aspiration. A late diagnosis is common, and this may aggravate tracheal damage due to persistent compression. DAA is found in approximately 1 in 2000– 4000 pregnancies on fetal echocardiography and in 1.5% of abnormal fetal echocardiography examinations. To our knowledge, there have been only a few reports on prenatal diagnosis of DAA . We recently encountered a case of DAA that was diagnosed prenatally.

Case Report

The Hokkaido University Hospital Institutional Review Board approved this study and the patient provided signed informed consent

A 36-year-old Japanese woman underwent screening echocardiography of spatiotemporal image correlation (STIC)including both grayscale and color Doppler studies at gestational week (GW) 23. The images revealed RAA and left arterial duct, but not LAA . Subsequent repeat echocardiographic examinations at GW 26, 29, 32, and 38 consistently suggested the presence of DAA with the trachea encircled by the RAA and LAA (Figure 2) and normal intracardiac anatomy. A female neonate was born by repeat cesarean section, weighing 2894 g with 1- and 5-minute Apgar scores of 8 and 9, respectively. Within 10 minutes after birth, she exhibited respiratory difficulty, including tachypnea, persistent stridor, and wheezing, and required inhaled oxygen with continuous positive airway pressure. Postnatal computed tomography (CT) angiography of the thorax confirmed the diagnosis of DAA with mild narrowing of the midtrachea in this patient. Surgical treatment, including division of the LAA and left arterial duct approached via the side of the arterial duct, was performed 10 hours after birth. The postoperative course was uneventful, and the infant left hospital at age 15 days. The infant was free from any symptoms when last seen at 1 month old.

The Use of Sobriety Nutritional Therapy in the Treatment of Opioid Addiction

Opioid addiction is a biological disease, and results in serious negative consequences for the individual and the social environment. Among the consequences are serious physical and emotional difficulties,legal, and negative social ramifications. In a study of drug harms in the United Kingdom heroin was found to be the most harmful to the individual, and in contrast, alcohol was the most harmful to others.

This research proposal will concentrate upon the physical health of the person with addiction, noting that addiction is a very complicated process with many layers and ramifications impacting individuals, families, groups, organizations and communities. The effects of malnutrition and changes in the neurochemistry of persons resulting from opioid addiction, and interventions to improve nutrition, neurotransmitter functioning, reduce craving, and promote social functioning is the focus of this proposal. The hypothesis is that providing nutritional food to patients enrolled in a methadone maintenance program will improve their health status, reduce craving, improve relapse rates, resulting in higher levels of social functioning. This paper will cover a review of the literature regarding the negative health effects resulting from opioid addiction, metabolic and emotional craving of the substance, and nutritional interventions. This will be followed by a discussion of the literature review findings, and how it applies to the proposed pilot study; a description of the study and methodology; rationale for the approach selected; followed by references cited.