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Hypertension in obese children and adolescents
Srpski Arhiv za Celokupno Lekarstvo , 2009, DOI: 10.2298/sarh0902091p
Abstract: Obesity, especially upper body fat distribution, has become an increasingly important medical problem in children and adolescents. Outcomes related to childhood obesity include, as in adult population, hypertension, type 2 diabetes mellitus, dyslipidemia, left ventricular hypertrophy, obstructive sleep apnea, orthopedic and socio-psychological problems. Obese children are at approximately 3-fold higher risk for hypertension from non-obese ones. Obesity-hypertension appears to be characterized by a preponderance of isolated systolic hypertension, increased heart rate and blood pressure variability, increased levels of plasma catecholamine and aldosterone, and salt-sensitivity. Lifestyle changes of weight loss, healthier diet and regular physical exercise are effective in obesity-hypertension control, though pharmacological treatment is frequently necessary. Screening for dyslipidemia and impaired glucose tolerance should be performed in paediatric patients with obese hypertension on regular basis, at least once annually or semiannually to discover metabolic syndrome and to prevent its increased cardiovascular risk. Of course, prevention of obesity is the primary goal. .
Management of idiopathic nephrotic syndrome in childhood
Srpski Arhiv za Celokupno Lekarstvo , 2004, DOI: 10.2298/sarh0410352p
Abstract: The management of idiopathic nephrotic syndrome (INS) in children includes immunosuppressive and symptomatic treatment. The response to corticosteroid therapy is the best prognostic marker of the disease. The majority of children with INS (about 85%) are steroid-sensitive as they normalize proteinuria within 4 weeks of daily, oral prednisone administration. The most of steroid-sensitive patients (94%) has minimal change of nephrotic syndrome, while the majority (80.5%-94.4%) of those who are steroid-resistant has focal segmental glomerulosderosis or mesangioproliferative glomerulonephritis. Initial therapy of INS consists of 60 mg/m2/day prednisone daily for 4 weeks followed by 40 mg/m2 on alternate days for 4 weeks, thereafter decreasing alternate day therapy every month by 25% over the next 4 months. Thus, the overall duration of the initial cortico-steroids course is 6 months that may be significantly protective against the future development of frequent relapses. Approximately 30% of patients experience only one attack and are cured after the first course of therapy; 10-20% have only 3 or 4 steroid-responsive episodes before permanent cure; the remaining 40-50% of patients are frequent relapsers, or steroid-dependent. Standard relapse therapy consists of 60 mg/m2/ day prednisone until urine is protein free for at least 3 days, followed by 40 mg/m2 on alternate days for 4 weeks. The treatment of frequent-relapses and steroid-dependent INS includes several different regimens: maintenance (6 months) alternate steroid therapy just above steroid threshold (0.1-0.5 mg/kg/ 48h), levamisole, alkylating agents (cyclophosphamide or chlorambucil) or cyclosporine. The worse prognosis is expected in steroid-resistant patients who are the most difficult to treat. Renal biopsy should be performed in them. At present, there is no consensus on therapeutic regimen for steroid-resistant patients. The following immunosuppressive drugs have been used with varying success: cyclosporine, intravenous methyl prednisone pulses alone or combined with or followed by alkylating agents, plasma-exchange, and angiotensin-converting enzyme (ACE) inhibitors. Symptomatic treatment includes: 1) dietary regimen with normal protein intake and salt restriction, 2) calcium and vitamin D are prescribed with steroids, 3) diuretics should be used in case of severe edema, 4) infusion of albumin in case of severe hypovolemia, 5) treatment of hypertension, 6) anticoagulant therapy, and 7) prophylactic antibiotics in high-risk patients.
Voiding dysfunction in children aged five to 15 years
Karaklaji? Dragana,Peco-AntiAmira
Srpski Arhiv za Celokupno Lekarstvo , 2004, DOI: 10.2298/sarh0410313k
Abstract: Voiding dysfunction in children was analyzed in 91 patients in a period from January 1st to October 1st 1998. Most of the patients had functional voiding disorder (92.31%), and only 7.69% manifested monosymptomatic night enuresis. The number of girls was bigger in the group of patients with voiding dysfunction while the boys were predominant in the group with mono-symptomatic nocturnal enuresis. More than a half of children with functional voiding disorder had repeated urinal infections (58.23%), incontinence (93.49%), need for urgent voiding (68.13%), and vesicoureteral reflux (47.61%). The most common type of voiding dysfunction was urge syndrome/urge incontinence. The incidence of dysfunctional voiding disorder was more often in children with scaring changes of kidney which were diagnosed by static scintigraphy.
Ambulatory blood pressure values in healthy children
Paripovi? Du?an,Peco-AntiAmira
Srpski Arhiv za Celokupno Lekarstvo , 2006, DOI: 10.2298/sarh0602030p
Abstract: Ambulatory blood pressure monitoring (ABPM) is an important tool in the diagnosis and management of childhood hypertension. Normal ambulatory blood pressure (ABP) values in children with body heights between 100 and 120 cm have not been reported. The aim of the study was to establish the normal range of values for ABPM in these children. 24-hour ABPM was performed in 40 normotensive (auscultatory casual blood pressure was obtained before ABPM) subjects, aged from 4 to 6 years (26 males, 14 females) with body heights between 95 and 125 cm. ABPM was carried out on non-dominant arm using the oscillometric device (SpaceLab 90207) with appropriate cuff size. The monitor was programmed to measure BP every 15 min. during the day (6 a.m. to 10 p.m.) and every 30 min. during the night (10 p.m. to 6 a.m.). The mean daytime SBP/DBP in boys and girls was 108+/-6/67+/-5 and 105+/-5/66+/-1, respectively. The mean nighttime SBP/DBP in boys and girls was 98+/-6/56+/-5 and 97+/-7/56+/-4, respectively. There was a significant difference between day and night readings of SBP, DBP and heart rate (nocturnal fall was observed). The distribution of ABP noted in this study could serve as preliminary reference. A multicenter study should be performed to provide normal ranges of ABP.
Chronic renal failure (CRF) in children in Jugoslavia
Peco-AntiAmira,Bogdanovi? Radovan,Golubovi? Emilija,?api? Milica
Srpski Arhiv za Celokupno Lekarstvo , 2003, DOI: 10.2298/sarh0302005p
Abstract: The aim of this study was to analyse the demographic variables of chronic non-terminal (CRF) and terminal (TRF) renal failure patients (pts) younger than 19 years treated in Serbia in June 2001. The prevalence of CRF pts was registered as 4,7 per million total population (pmtp) or 14,1 per million child population (pmcp) while corresponding values for TRF pts were 4,5 pmtp or 13,5 pmcp. The incidence of TRF pts during the period Jan.2000-Jan.2002 was 4,35 pmcp. Boys dominated only among CRF pts (34:14); 60,4% beeing between the ages of 6 and 19 yrs while at the time of diagnosis of HBI, 33,3 % of boys were yanger than 2 yrs.The causes of CRF were: reflux nephropathy 58,3%, congenital kidney disease 16,7%, familial/hereditary 14,6% glomerulonephritis 6,2% and Willms tu 4,1%. Reflux nephropathy was also the most common underlying disease of TRF accounted for 36,9% of total cases while glomerulonephritis was responsible for 23,9 %. Reflux nephropathy was associated with neural tube defect in 53,3% and with congenital lower urinary tract obstruction in 66,7%. The most of CRF (81,25%) and TRF pts (95,6%) were from Serbia, the others were from Monte Negro and Republic Srpska. The most of CRF (65%) and TRF (80%) pts were treated in University Children’s Hospital in Belgrade. Of CRF pts 46% had serum sreatinine 100-200 μmol/l, in 11% of pts it was 400-600 μmol/l and 2% of pts were in pre-terminal CRF. One third of CRF pts had proteinuria 150-500 mg/l, and second third had proteinuria greater of 1000 mg/l. Anemia was present in 54% of CRf pts, and arterial hypertension in 56%. Hemodialysis was dominant treatment modality for TRF pts and only 23,9% had functioning transplant. Conclusion: This is the first national study of demographic characteristics of pediatric CRF in Serbia. Since its prevalence is considerably lower than that in Western and North European countries the true prevalence is some what higher. The increasing incidence of pediatric TRF from 2,85 pmcp to 4,35 pmcp reflect better diagnosis and treatment of these patients in the recent years.
Estimation of representative blood pressure values in haemodialysed children
Pej?i? Iris,Peco-AntiAmira,Kosti? Mirjana M.
Srpski Arhiv za Celokupno Lekarstvo , 2002, DOI: 10.2298/sarh0210306p
Abstract: The diagnosis of hypertension in patients on chronic haemodialysis is not easy because the blood pressure changes as a consequence of therapy (haemodialysis) and attenuated circadian rhythm of blood pressure is often present. The estimation of representative blood pressure levels is difficult because it is not known whether blood pressures measured before starting or after completion of haemodialysis are predictive for the average interdialytic blood pressure. Our group of patients consisted of 18 children with endstage renal failure, aged 13.5 ± 3.2 years, treated with chronic haemodialysis from 0.1 to 110 (mean 25.8, median 19) months. Ambulatory blood pressure monitoring was performed during 44h interdialytic period. Blood pressure was also measured with sphygmomanometer before starting and after completion of heamodialysis. The average blood pressure values for the last ten haemodialyses were evaluated as well. Multiregression analysis showed significant correlation between interdialytic blood pressure (systolic and diastolic) and blood pressures measured before haemodialysis (r = 0.74; ρ < 0.001, r = 0.78; ρ < 0.001, respectively) and after haemodialysis (r = 0.76; ρ < 0.01, r = 0.6; ρ < 0.05, respectively). Statistically high correlation between these blood pressures was also confirmed for the average blood pressure values for the last 10 haemodialyses (r = 0.78; ρ < 0.001, r = 0.75; ρ < 0.001 and r = 0.78; ρ < 0.001, r = 0.86; ρ < 0.001, respectively). Our findings show that blood pressures measured before starting or after completion of haemodialysis give good information about interdialytic blood pressure in children on chronic haemodialysis.
Acute renal failure in asphyxiated term neonates
Pejovi? Biljana,Peco-AntiAmira,Dunji? Radica
Srpski Arhiv za Celokupno Lekarstvo , 2002, DOI: 10.2298/sarh0212367p
Abstract: INTRODUCTION Acute renal failure (ARF) is a frequent clinical condition in neonatal intensive care units (NICU). The leading cause of neonatal ARF is perinatal asphyxia (PS). The aim of this study was to examine the relationship between the degree of PS and the severity of ARF in term neonates. METHODS A prospective survey of 31 term neonates with Ps and but without congenital malformations or sepsis was performed in NICU of the regional Hospital of Gynaecology and Obstetrics in Belgrade (average number of deliveries about 6000 per year). ARF was diagnosed in the first 7 days of life when plasma creatinine was above 133 μmοΙ/L for at least 48 hours while maternal renal function was normal. The degree of PS was determined according to Apgar score (AS) at 1 min. The severe PS was defined as AS < 3 and moderate PS as AS 4-6. RESULTS Twenty neonates (64%) had oliguric ARF with urine output of 0.37 ±0.16 ml/kg/h while the others had nonoliguric ARF with urine output of 2.4 ± 0.7 ml/kg/h. Most of neonates with oliguric ARF (65%) had severe perinatal asphuxia while in those with nonoliguric ARF moderate perinatal asphyxia predominated (73%). DISCUSSION During hypoxic-ischaemic events many organs are injured, and the most vulnerable ones are kidneys and central nervous system. Our results showed a strong connection between perinatal asphyxia and A, which was in accordance with the results of other studies. Neonates with severe perinatal asphyxia had serious impairment of renal function, which was confirmed with strong correlation between Apgar score and plasma creatinine. In neonates with oliguric ARF, but not in those with nonoliguric ARF, the highly positive linear correlations were found between AS and urinary output (r = 0.77; p < 0.01), plasma creatinine (r = 0.78; p < 0.01), fractional excretion of sodium (r = 0.76; p < 0.01), and index of renal failure (r = 0.80; p < 0.01). Only in oliguric neonates with severe perinatal asphyxia (31 %) the outcome was fatal. CONCLUSION We conclude that in tgerm neonates with severe perinatal asphyxia oliguric ARF was the predominant type of ARF. There is a good prediction of the severity of oliguric ARF according to the degree of perinatal asphvxia determined by Apgar score at 1 min.
Pseudo-Bartter syndrome in an infant with congenital chloride diarrhoea
Igrutinovi? Zoran,Peco-AntiAmira,Radlovi? Nedeljko,Vuleti? Biljana
Srpski Arhiv za Celokupno Lekarstvo , 2011, DOI: 10.2298/sarh1110677i
Abstract: Introduction. Pseudo-Bartter syndrome encompasses a heterogenous group of disorders similar to Bartter syndrome. We are presenting an infant with pseudo-Bartter syndrome caused by congenital chloride diarrhoea. Case Outline. A male newborn born in the 37th gestational week (GW) to young healthy and non-consanguineous parents. In the 35th GW a polyhydramnios with bowel dilatation was verified by ultrasonography. After birth he manifested several episodes of hyponatremic dehydration with hypochloraemia, hypokalaemia and metabolic alkalosis, so as Bartter syndrome was suspected treatment with indomethacin, spironolactone and additional intake of NaCl was initiated. However, this therapy gave no results, so that at age six months he was rehospitalized under the features of persistent watery diarrhoea, vomiting, dehydration and acute renal failure (serum creatinine 123 μmol/L). The laboratory results showed hyponatraemia (123 mmol/L), hypokalaemia (3.1 mmol/L), severe hypochloraemia (43 mmol/L), alcalosis (blood pH 7.64, bicarbonate 50.6 mmol/L), high plasma renin (20.6 ng/ml) and aldosterone (232.9 ng/ml), but a low urinary chloride concentration (2.1 mmol/L). Based on these findings, as well as the stool chloride concentration of 110 mmol/L, the patient was diagnosed congenital chloride diarrhoea. In further course, the patient was treated by intensive fluid, sodium and potassium supplementation which resulted in the normalization of serum electrolytes, renal function, as well as his mental and physical development during 10 months of follow-up. Conclusion. Persistent watery diarrhoea with a high concentration of chloride in stool is the key finding in the differentiation of congenital chloride diarrhoea from Bartter syndrome. The treatment of congenital chloride diarrhoea consists primarily of adequate water and electrolytes replacement.
Infantile nephropathic cystinosis
Peco-AntiAmira,Kosti? Mirjana,Bogdanovi? Radovan,Spasojevi? Brankica
Srpski Arhiv za Celokupno Lekarstvo , 2011, DOI: 10.2298/sarh1108486p
Abstract: Introduction. Infantile nephropathic cystinosis (INC) is a metabolic disorder due to impaired carrier-mediated transport of cystine out of cellular lysosomes. Objective. To examine the prevalence and clinical characteristics of INC in paediatric patients with end- stage renal disease (ESRD) in Serbia and give a recent statement of the disease. Methods. ESRD database of the Centre for Paediatric Renal Replacement Therapy (RRT) in Serbia was used to identify all patients with INC who started RRT before age of 19 years during the period January 1980 - December 2008; their records concerning clinical characteristics, therapy and outcome were evaluated. Results. Only three of 298 paediatric patients with ESRD had INC. The first signs of the illness were recognised during infancy. Fancony syndrome was diagnosed in the second year, but the diagnosis of cystinosis was delayed at mean 6 years. ESRD occurred in the first decade of life. All patients under- went cadaver kidney transplantation. At the end of the study period all patients were alive. A 31-year-old female patient was on maintenance chemodialysis due to graft failure after functioning for 11 years. She was growth retarded, single, unemployed, with severe signs of renal dystrophy. Two male patients (14.3 and 14.7 years old) had normal graft function, normal education, and good quality of life, although they were also severe growth retarded. Conclusion. The prevalence of infantile nephropathic cystinosis is low in Serbia. The diagnosis of cystinosis was delayed in all patients, although they exhibited the typical course of the disease.
Renal scintigraphy in infants with antenatally diagnosed renal pelvis dilatation
Ajdinovi? Boris,Jaukovi? Ljiljana,Peco-AntiAmira,Dugonji? Sanja
Vojnosanitetski Pregled , 2008, DOI: 10.2298/vsp0804299a
Abstract: Background/Aim. Ureteropelvic junction obstruction and vesicoureteral reflux are the most frequent entities identified on the basis of antenatal hydronephrosis. The aim of this study was to determine the incidence and pattern of abnormal renal scintigraphy findings in postnatal investigation of children with antenatal hydronephrosis. Methods. Twenty four infants (19 boys and five girls) presented with antenatal hydronephrosis and mild to moderate hydronephrosis on ultrasound in newborn period were referred for renal scintigraphy. Ten patients with vesicoureteral reflux documented on micturating cystoureterography underwent 99mTc-DMSA renal scintigraphy and 14 patients were subjected to 99mTc-DTPA scintigraphy. Results. Anteroposterior pelvic diameter on ultrasound ranged from 11 to 24 mm. Renal DMSA scans identified congenital scars in two boys with bilateral reflux of grade V and unilateral reflux of grade III. Relative kidney uptake (RKU) less than 40% was found in three, and poor kidney function (RKU less than 10%) in two patients. Significant obstruction was shown on DTPA diuretic renal scintigraphy in 6/14 patients. Some slowing in dranaige (T1/2 greater than 10 minutes) with no reduction in differential renal function was identified in three patients. Differential renal function less than 10% was obtained in one case. Conclusion. A high percent of abnormal renal scintigraphy findings was obtained. Renal scintigraphy was useful in determination of underlying cause of antenatally detected hydronephrosis.
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