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Urinary tract infection is a common and frequently recurring condition in children. The susceptibility of the host, the presence of urinary tract abnormalities, and the virulence of the urinary pathogens are of primary importance in the development of the infection. Renal parenchymal scarring, hypertension, and renal insufficiency are well-established complications of the infection in children. To reduce the risk of renal damage, diagnosis and treatment must be prompt. The diagnosis demands radiologic evaluation of the urinary tract in all boys, all children younger than 5 years, all patients with voiding dysfunction, and school-aged girls with recurrent infection to identify those patients with vesicoureteral reflux, obstruction, or other urinary tract abnormalities. Both voiding cystourethrography and renal ultrasonography are the initial examinations to use to determine the next appropriate study. Children with vesicoureteral reflux or with recurrent urinary tract infections should receive prophylactic antibiotic therapy and should be observed closely to prevent renal scarring.
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PMID:Urinary tract infections in children. An update. 144 14

Previous studies suggesting that maternal undernutrition increases the risk of preterm birth have suffered from several methodological shortcomings, including use of total gestational weight gain rather than net rate of gain in maternal tissue, inclusion of induced preterm deliveries, and error-prone gestational age measurements based solely on menstrual dates. The authors have attempted to overcome these shortcomings by investigating the potential etiologic roles of prepregnancy body mass index, net rate of maternal weight gain, height, and a number of other potential biological and sociodemographic determinants of spontaneous (i.e., noninduced) preterm birth in a cohort of 13,102 women with early ultrasound-confirmed gestational age who delivered at the Royal Victoria Hospital in Montreal, Quebec, Canada, between January 1, 1980 and March 31, 1989. Total weight gain, but not body mass index, was highly significantly associated with spontaneous preterm birth, averaging 14.6, 12.5, 9.9, and 9.1 kg, in women delivering at 37 or more, less than 37, less than 34, and less than 32 completed weeks, respectively. Although the relation persisted when weight gain was expressed as an overall rate, it disappeared when the analysis was based on net rate; mean net rates of gain were 0.28, 0.29, 0.27, and 0.27 kg/week, respectively. On the basis of multiple logistic regression analyses, significant determinants of birth at less than 37 weeks included maternal short stature; noncompletion of high school; unmarried status; smoking; diabetes; urinary tract infection within 2 weeks of delivery; prepregnancy hypertension; severe pregnancy-induced hypertension; and previous history of preterm delivery, low birth weight, or neonatal death. Most of these factors retained their significance for birth at less than 34 and less than 32 weeks. In fact, the effect of low maternal education was even stronger at these more severe "levels" of preterm birth. The authors conclude that prepregnancy weight-for-height and gestational weight gain are not important determinants of spontaneous preterm birth and that some previous studies have mistaken an effect of shortened gestation for its cause. Other biologic and social determinants, however, indicate priorities for future research and intervention.
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PMID:Maternal nutrition and spontaneous preterm birth. 144 21

A series of 23 confirmed cases of pyonephrosis initially treated by percutaneous nephrostomy drainage were reviewed. Presentation was extremely variable, ranging from sepsis to asymptomatic bacteriuria. Fever, flank pain and leukocytosis were often absent. Ultrasonography was diagnostic in only 3 of 12 patients. In all, 17 patients had associated nephrolithiasis, and 5 patients ultimately required nephrectomy. Renal urine cultures were positive in 16 of 21 instances, with multiple organisms found in 8 of 21, and added bacteriological data not provided by bladder urine cultures in 11 cases. A pre-existing history of urinary tract infection, hypertension and malignancy was common. Percutaneous drainage was a safe, quick and effective diagnostic and therapeutic method.
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PMID:Pyonephrosis: diagnosis and treatment. 145 Aug 41

Renal ultrasound examination, performed following a urinary tract infection in a 4.5-year-old girl with triple X syndrome, showed multiple echogenic foci at the corticomedullary junction in both kidneys. She was asymptomatic but had hypertension with echocardiographic evidence of left ventricular hypertrophy. Computerised tomographic scan revealed foci of calcification in the kidneys, spleen and pancreas. On biopsy calcification was found in the internal and external elastic laminae of the superficial temporal artery and in the internal elastic lamina of a renal arcuate artery. Intimal fibrosis was mild and focal. No other arterial calcification was demonstrated radiographically or by ultrasound. Biochemical and hormonal profiles revealed no abnormality except hypercalciuria. The aetiology and prognosis of this child's condition are unknown. Although similar ultrasound and histological appearances have been described in pseudoxanthoma elasticum and in idiopathic arterial calcification of infancy, there is no evidence that the child has either of these conditions.
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PMID:Hypertension associated with diffuse small artery calcification: a case report. 148 46

Urinary tract infections (UTI) may become dangerous if ascending bacteria reach the kidney and subsequently induce an inflammatory reaction within the renal parenchyma. Host factors like vesicorenal reflux or obstructive uropathies increase the risk of ascending infection and facilitate renal damage even by bacteria of "low virulence". Inadequate antibiotic therapy and young age are further predisposing factors for pyelonephritic scars. Hypertension, reduced kidney function and complications during pregnancy are the potential long term problems arising from renal damage. Early recognition of obstructive uropathies by sonographic screening, undelayed diagnosis and consequent treatment of symptomatic UTI, and early identification of reflux after symptomatic UTI's may reduce the incidence of these problems.
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PMID:[How dangerous is a urinary tract infection?]. 149 4

Histology records from 63 nephrectomies were reviewed; 22 patients had unilateral totally dysplastic kidneys and 5 had polar or segmental dysplasia. A clinicopathological study of these cases was undertaken. In the first group, there was a slight male preponderance and 75% of the patients presented were under two years of age. Urinary tract infection was the most common complaint. 4 patients were diagnosed in utero by ultrasound and 5 infants presented an abdominal mass. Hypertension was documented in a newborn baby. Ipsilateral lower urinary tract anomalies were found in 12 patients and those of the contralateral kidney in 2 children. There were 3 cases of extrarenal anomalies. Histological examination revealed 13 cases of multicystic dysplasia and 9 of solid dysplasia. Metaplastic cartilage was found in 1 case. In the group of segmental dysplasia, age ranging from 27 weeks' gestation to 8 years, at the time of the diagnosis. They all had duplex kidneys and 4 had ureterocele. Histological study in these cases was similar to the one found in the previous series, although superimposed inflammatory changes were more pronounced. Some of the theories regarding the pathogenesis of this disorder are reviewed and the importance of its diagnosis is emphasised.
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PMID:[Renal dysplasia: clinico-pathologic review]. 150 40

Eight women with insulin-dependent diabetes mellitus (IDDM) with low creatinine clearance rate (CCR) and normal urinary albumin excretion (UAE) were compared with three other groups of diabetic women: 19 with normal creatinine clearance rate (CCR) and UAE, 7 with normal CCR and microalbuminuria, and 7 with low CCR and microalbuminuria. The four groups were similar in age, duration of diabetes, HbA1, incidence of urinary tract infection, prevalence of bladder neuropathy, and urinary urea nitrogen excretion rate. The prevalence of hypertension was similar among the groups, although mean arterial pressure was higher in the low CCR and microalbuminuria group. Renal area index was lower in the low CCR and normal UAE groups than in the other groups of diabetic patients, but was not different from normal. Morphometric measures of mesangial expansion and estimates of arteriolar hyalinosis and global glomerulosclerosis were increased to a similar degree in the low CCR and normal UAE, normal CCR and microalbuminuria, and low CCR and microalbuminuria groups compared with the group without abnormalities of renal function. Therefore, it is likely that diabetic glomerulopathy is, at least in part, responsible for the loss of glomerular filtration rate seen in the low CCR and normal UAE patients. Thus, the definition of incipient nephropathy may have to be expanded beyond the concept of microalbuminuria if longitudinal study of such patients reveals an increased risk of the subsequent development of overt nephropathy. Finally, screening for diabetic kidney disease among IDDM patients should include determination of glomerular filtration rate and measurement of UAE and blood pressure, especially among women.
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PMID:Glomerular structure in IDDM women with low glomerular filtration rate and normal urinary albumin excretion. 156 27

Congenital urinary tract obstruction is a common cause of renal failure accounting for up to 20% of end-stage renal disease cases. Intrauterine obstruction often results in parenchymal loss and renal dysfunction. The pathophysiology of obstructive nephropathy and its further depression of renal function is related to severe renal vasoconstriction, which is in large part angiotensin mediated. Signs suggestive of urinary obstruction in the newborn may include an abdominal mass, hypertension, oligoanuria/polyuria, urosepsis, and hyperchloremic acidosis. The combination of renal ultrasound, diuretic renal scans, and voiding cystourethrogram are the main diagnostic modalities in infants with hydronephrosis. Nonsurgical management of ureteropelvic junction obstruction has become more popular, particularly in mild to moderate cases. Early fulguration or bypassing the obstruction of urethral valves is essential and a decrease in serum creatinine to below 1 mg/dL within 1 month of relief of obstruction is a favorable prognostic sign. Obstruction complicated by infection is dangerous and requires prompt intervention. Any newborn with a urinary tract infection, regardless of sex, should be presumed to have urinary obstruction or reflux until proven otherwise.
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PMID:Urinary tract obstruction and infection in the neonate. 157 69

A total of 26 non-insulin-dependent diabetic patients were enrolled for a clinical study of the effect of buflomedil on microalbuminuria. None of the subjects had hypertension or macroproteinuria. Sixteen cases without previously known urinary albumin excretion rate (AER) were enrolled as experimental group. Buflomedil (Loftyl) was administered orally 600 mg daily in two divided doses in the experimental group while AER was determined 3 times with 3 weeks apart in all of the subjects. Ten cases with known microalbuminuria (greater than 8.55 micrograms/min) were enrolled as control group to check the extent of fluctuation in AER from collection to collection in the absence of urinary tract infection. Six of the experimental group showed AER of microalbuminuric level at the time before buflomedil administration and the remaining 10 patients were normoalbuminuric. The effects of buflomedil were compared between the microalbuminuric and normoalbuminuric subjects in the experimental group. The microalbuminuric group showed a significant decrease of AER from a baseline of 30.4 micrograms/min to 19.8 and 16.8 micrograms/min, respectively, after 3 and 6 weeks of treatment (P less than 0.05, Friedman two-way ANOVA). However, the respective values in the normoalbuminuric group were 5.3, 5.6 and 5.0 micrograms/min (P greater than 0.05, Friedman two-way ANOVA). The AER in the control group remained stationary during the study period (14.0, 12.1 and 11.4, respectively, Friedman two-way ANOVA, P greater than 0.05). These results suggest that buflomedil might be beneficial for the patients with microalbuminuria.
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PMID:The effect of oral buflomedil on microalbuminuria in non-insulin-dependent diabetic patients. 160 Aug 49

Reflux nephropathy is characterized by the presence at radiological examination of one or several segmental scars in the renal parenchyma, associated with vesico-ureteral reflux. Histology displays a variety of lesions, among which chronic and atrophic pyelonephritis, segmental hypoplasia and renal dysplasia can be individualized. Most of these renal lesions can be prevented by early detection of the reflux which encourages the development and recurrence of urinary tract infection and its diffusion to the upper urinary tract and the kidneys. The finding of a vesico-ureteral reflux with renal lesions, even after spontaneous or surgical regression of this reflux, requires prolonged surveillance in view of the long-term risk of arterial hypertension and renal failure.
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PMID:[Reflux nephropathy]. 160 64


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