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Objectives: To compare characteristics and outcomes of vesicoureteral reflux (VUR) detected solely on isotopic cystography (IC) ("occult" VUR) with voiding cystourethrography (VCUG)-detected VUR., Materials and Methods: Between 2015 and 2020, we retrospectively enrolled all male children first undergoing VCUG and, if negative, IC in the same session. Kidney injury (KI) was defined by abnormal estimated glomerular filtration rate and/or blood pressure and/or proteinuria., Results: We enrolled 421 males with a median age of 3 months and a follow-up of 5.3 years. None exhibited KI initially, but 10% of those with VUR developed KI during follow-up. Two hundred and twenty-two patients (52.7%) did not show VUR, 152 (36.1%) had VCUG-diagnosed VUR, and 47 (11.2%) had occult VUR. Therefore, 47/199 patients (23.6%) with VUR had occult VUR. Among these, 34/47 (72.3%) had dilated VUR, and 22/47 (46.8%) exhibited split renal function < 45% and/or scar (scintigraphic damage). Compared to patients with occult VUR, those with VCUG-diagnosed VUR showed a similar prevalence of febrile urinary tract infection (fUTI) before and after VUR diagnostics and KI at the last follow-up but a higher prevalence of dilated VUR, of scintigraphic damage, and underwent surgery more frequently. At multiple logistic regression analysis, patients with VCUG-diagnosed VUR presented an increased risk of fUTI either before or after VUR diagnosis and of KI, while patients with occult VUR presented an increased risk of fUTI before (and among patients with dilated VUR also after) VUR diagnosis and of KI., Conclusion: Occult VUR affects 23.6% of male children with VUR with a non-negligible risk of VUR-associated KI and fUTI. IC could select, among males with recurrent fUTIs and negative VCUG, those requiring surgery for a possible dilated occult VUR., Clinical Relevance Statement: Vesicoureteral reflux may be overlooked in 25% of boys during VCUG, yet they are at risk of fUTIs and KI. In case of recurrent infections post-negative cystourethrography, IC could detect occult reflux, guiding surgical intervention., (© 2024. The Author(s).)

Background: Acute kidney injury (AKI) enhances the risk of later chronic kidney disease. Significant prevalence of AKI is reported in adults with community acquired pneumonia (CAP). We investigated prevalence of and prognostic factors for AKI in children hospitalized for CAP., Methods: We retrospectively collected clinical and biochemical data of 186 children (48.4% male; mean age 2.6±2.4 years) hospitalized for X-ray-confirmed CAP. AKI was defined according to Kidney Disease/Improving Global Outcomes creatinine criteria. We considered as basal serum creatinine the value estimated with Hoste (age) equation assuming basal eGFR were median age-based eGFR normative values for children ≤ 2 years of age and eGFR= 120 mL/min/1.73m 2 for children > 2 years. Univariate and multivariate logistic regression models were used to explore associations with AKI., Results: AKI was found in 38/186 (20.4%) patients. No patient required hemodialysis nor reached AKI stage 3, 5 (2.7%) reached AKI stage 2, and 33 (17.7%) AKI stage 1. Mean length of stay was 6.0±1.7, 6.9±2.3, and 12.2±1.5 days, for patients without AKI, stage 1 AKI, and stage 2 AKI (p < 0.001), respectively. Duration of symptoms before hospitalization (OR 1.2; 95%CI 1.09-1.43; p = 0.001), severe pneumonia (OR 11.9; 95%CI 4.3-33.3; p < 0.001), and serum C-reactive protein levels (OR 1.1; 95%CI 1.04-1.23; p = 0.004) were independent AKI predictors., Conclusions: About 1/5 of children hospitalized for CAP present a generally mild AKI with a longer stay for those with more severe AKI. Attention should be paid to kidney health of children with CAP especially in presence of higher duration of symptoms before hospitalization, severe pneumonia and higher serum CRP levels., (© 2021. The Author(s).)

Although pediatricians are frequently confronted with patients presenting urolithiasis symptoms without obvious stones, the syndrome of occult urolithiasis may be still viewed with some skepticism. We have compared the clinical and metabolic features of 197 children with obvious calculi, 189 with microcalculi (diameter ≤ 3 mm based on renal sonography), and 114 with symptoms of urolithiasis and normal renal sonography findings. Only microcalculi and normal sonography subjects with a urinary abnormality potentially leading to urolithiasis were included in the study. Age at presentation increased significantly (p = 0.0001) in the groups in the order normal sonography to microcalculi to calculi groups. There was no significant difference among the three groups in terms of family history of urolithiasis, gender distribution, and degree of hypercalciuria, hyperuricosuria, hyperoxaluria, or hypocitraturia. The average frequency of pain attacks of patients with recurrent abdominal pain (RAP) ranged from 3.6 to 4.6 days of pain per month among the three groups, which is four to ninefold lower than that reported for children with functional or organic gastrointestinal RAP. The consistency of many clinical and urinary metabolic characteristics indicates a common underlying disorder in overt and occult urolithiasis. The increase of age at presentation from the normal sonography to microcalculi and calculi groups may reflect progressive crystal accretion leading ultimately to overt stone formation.

The finding of scintigraphic renal defects in children with febrile urinary tract infection (UTI) even in the absence of vesicoureteric reflux (VUR) has led to the conclusion that VUR is a weak predictor of renal defects in these patients. We used isotopic cystography (IC) for diagnosis of VUR in children with febrile UTI. Dimercaptosuccinic acid renal scintigraphy was performed 6 months after cure of the last UTI. Renal defects were defined by the finding of focal defects of radionuclide uptake and/or by a split renal function <43%. The study included 206 children with primary VUR and 77 without VUR. Among the subjects with and without VUR, respectively, renal defects were found in 40 and 6% (p=0.0001), focal uptake defects in 33 and 5% (p=0.0001) and split renal function <43% in 26 and 5% (p=0.0001). Permanent renal defects in children with febrile UTI are closely associated with VUR. The possibility that a child will have permanent renal defects can reasonably be ruled out on the basis of the absence of VUR by IC.

Sports hematuria has been described in adult athletes. We report on two boys with gross hematuria after soccer matches. Urinalysis was negative for hematuria at the first visit. A simple test of effort provoked the phenomenon and allowed the detection of the post-renal origin of bleeding and the rapid resolution of hematuria. Such a test may be particularly helpful after the first episode, when it is problematic to postulate a cause-effect relationship between exercise and hematuria on the basis of the patients' history.

Growth retardation and osteopenia have been reported in some children with idiopathic hypercalciuria (IHC), particularly in those with nephrocalcinosis. The duration of hypercalciuria might be a risk factor for osteopenia. A retrospective longitudinal analysis of statural growth and a cross-sectional evaluation of bone mineral density (BMD) was carried out in 26 IHC children followed for 4-13 years. None of the patients had nephrocalcinosis. Growth, including pubertal growth spurt, was normal in all subjects. BMD Z score less than -1 was recorded in 3 subjects with hyperuricosuria. BMD Z score averaged -0.68+/-0.99 in the 9 subjects with associated hyperuricosuria and 0.21+/-0.64 in the 17 with occasional or no hyperuricosuria ( P=0.018). Our analysis shows that children with long-lasting IHC without nephrocalcinosis have normal growth, but those with associated hyperuricosuria may be at risk for osteopenia.

Idiopathic hypercalciuria (IHC) has been reported mainly in children with hematuria in the 1980s and early 1990s, when renal sonography was just becoming routine. The presence of microcalculi, i.e., of hyperechogenic spots < 3 mm in diameter in renal calyces, was not taken into account in those studies. We attempted to outline clinical presentation and natural course of IHC not only in children with hematuria, but also in those with dysuria and/or recurrent abdominal/flank pain and a family history of nephrolithiasis, taking into account the finding of microcalculi. We analyzed retrospectively the data at diagnosis from 74 consecutive children aged 2.4-18 years (mean 8.6) with IHC (calciuria 4.1-15.1 mg kg-1 24 h-1, mean 6.1) and the outcome of 30 of them who were followed > or = 1 years (mean 3.2) with no specific therapy. At diagnosis, 38 patients (51%) had no hematuria, 42 (57%) had microcalculi and four (5%) had calculi. Of the patients with normal urinalysis, 71% had microcalculi or stones. The subjects with microcalculi and those with stones were significantly older than those without microcalculi and stones (P = 0.004 and 0.007). A normal urinalysis at our evaluation and a history of abdominal/flank pain were significantly more frequent in patients with microcalculi than in those without (P = 0.02 and 0.0001, respectively). During the follow-up, four of 30 patients formed stones 1-3 years after first diagnosis of IHC. More than half of children with IHC have microcalculi. The risk of formation of microcalculi or stones increases with age. The lack of hematuria does not exclude the presence of microcalculi or calculi. Hypercalciuria has to be suspected in children with dysuria and/or recurrent abdominal flank pain and a family history of nephrolithiasis, even when they have no hematuria.

We studied the prevalence of a history of nephrolithiasis in first- and second-degree relatives of 74 children with hypercalciuria (HC), 61 with hyperuricosuria (HU), and 41 with HC plus HU, and in a control population of 261 children with different diseases. Family history of nephrolithiasis was found in 69% of HC, 75% of HU, 78% of HC plus HU, and 22% of control patients. The prevalence was not different among HC, HU, and HC plus HU groups, but was significantly higher in each study group than the control group (P=0.0001). Body mass index >95th percentile was found in only 4.7% of the patients with HC or HC plus HU. Calculi (>3 mm in diameter) were present in 8.9% of the patients with a family history of nephrolithiasis and in 9.4% of those with no family history (P=0.85). Microcalculi (<3 mm in diameter) were found by sonography in 56.6% of the patients with and in 53.3% of those without a family history of nephrolithiasis (P=0.83). Children with HC and/or HU have a strong familial prevalence of nephrolithiasis. Obesity does not seem to affect the association of familial nephrolithiasis and hypercalciuria in children. The presence of nephrolithiasis in families of children with HC and/or HU is not associated with a higher rate of formation of calculi or microcalculi.

We compared the accuracy of isotope cystography (IC) and fluoroscopic cystourethrography (FC) in detecting vesicoureteric reflux (VUR) in children. FC and IC were performed in 124 children, 56 boys and 68 girls, aged 1 month to 9.2 years (mean 2.1 years), admitted consecutively for suspected VUR over a 10-month period. VUR was diagnosed by one or both studies in 51 of 124 (41%) patients. The two methods were concordant for the detection of VUR in 84% of kidney-ureter units and in 93% for the detection or exclusion of severe VUR. IC detected VUR more accurately than FC, both when all grades of VUR were considered together (P=0.00001) and when only severe reflux was considered (P=0.004). VUR was missed by FC in 23 of 51 (45%) subjects. Of those 23, 12 had severe VUR detected on one side at least by IC. VUR was missed by IC in 3 subjects. IC is significantly more accurate than FC in the initial diagnosis of VUR, even of severe grade. IC is the method of choice for the first diagnosis of VUR. Boys with VUR diagnosed by IC also need FC to investigate for posterior urethral valves.

Cyclic voiding cystourethrography (CVC) enhances the detection of vesicoureteric reflux (VUR). We investigated whether more-severe VUR may be overlooked, and whether older children are at risk of having their VUR missed with the conventional single-cycle study. Three hundred and seventy patients, 168 boys and 202 girls aged 1 month to 16 years, consecutively admitted over 1 year for suspicion of VUR, underwent two complete cycles of filling and voiding CVC. One hundred and four subjects, 33 boys and 71 girls, were older than 3 years (mean age 5.7 years, range 3.2-16 years). Sixty-six refluxing ureters from 51 patients were identified in the first cycle and 61 refluxing ureters from 45 patients were identified only with the second cycle. Four instances of grade IV VUR in 4 patients and three of grade V VUR in 3 patients were overlooked completely in the first cycle. Seven episodes of VUR < or = grade III from 5 patients diagnosed in the first cycle were upgraded to > or = grade IV at the second cycle. The presence of VUR was identified only in the second cycle in 35 of 74 subjects aged < or = 3 years and in 10 of 22 aged > 3 years (not significant). Of the 10 children aged > 3 years, 2, who had diagnosis only at the second cycle, had > or = grade IV VUR. More-severe VUR may be overlooked or down-graded in a single-cycle study. Two-cycle CVC is also useful in children older than 3 years.

Body growth was studied in 32 subjects with vesicoureteric reflux (VUR), diagnosed following the prenatal finding of urinary tract dilatation, who had normal renal filtration function and who received antibacterial prophylaxis by the first few days of life. They were followed for 1-5 years (mean 2.3 years). Most had persistent VUR during the 1st year of life. Body growth performance was compared with that of 94 subjects with VUR diagnosed and treated by us after the neonatal period. During the follow-up period, none of the patients with prenatally detected VUR had a height Z score below -2, nor a weight-for-height index below 90%, and 1 had variations in height Z score >/=1. The difference in the percentage of patients with prenatally detected VUR (1/32) and those with VUR diagnosed and treated after the neonatal period (20/94) who had variations in height Z score >/=1 was significant (P=0.035). Patients with prenatally detected VUR and normal renal filtration function, given antibacterial prophylaxis by the first few days of life, have normal body growth, although VUR still persists.

Recognition of children at greatest risk for urolithiasis may allow early detection or prevention of stone formation. We report clinical data from 196 children aged 0.9-15.9 years in whom renal ultrasound examination revealed hyperechogenic spots in renal calyces less than 3 mm in diameter. We called this finding "calyceal microlithiasis" (CM). There was a history of urolithiasis in 70.4% of patients in at least one first- or second-degree relative. Presenting symptoms were recurrent abdominal pain, dysuria, and hematuria, occurring alone or in combination. Hematuria was the presenting symptom in 41% of patients and was the only urinary finding in more than one-third. Hypercalciuria was present in about one-third and hyperuricuria in one-fifth of the patients. Of 29 patients who were followed for at least 2 years, 9 developed calculi 4-7 mm in diameter. CM possibly represents the first step in calculus formation. The finding of CM might explain a number of symptoms and signs that are often mild and non-specific, thus reducing invasive diagnostic procedures.

An 8-year-old girl with systemic lupus erythematosus (SLE) and diffuse proliferative glomerulonephritis had chronic interstitial cystitis (CIC) early in the course of SLE. The early occurrence of CIC, the lack of intestinal symptoms, the association with vesicoureteric reflux, and the improvement of CIC during therapy with cyclosporin A were the prominent features of the patient reported here.

A longitudinal retrospective study of height Z score (HZ score) and weight-for-height index (WHI) was performed on 94 pre-pubertal children with vesico-ureteric reflux (VUR) and normal creatinine clearance followed for 1-6.8 years (mean 3.1 years). Thirty patients had bilateral VUR with scintigraphic signs of renal scarring (B+), 17 had bilateral VUR without renal scarring (B-), 27 had unilateral VUR with (U+) and 20 unilateral VUR without (U-) renal scarring. Thirty-three patients received only antimicrobial medication and 61 underwent successful antireflux operation. The increase in HZ score and WHI during the 1st year of follow-up was significantly (P = 0.001 and 0.00003, respectively) higher than during the 2nd year. At first visit, B+ subjects had an average WHI and HZ score that were significantly (P = 0.02 and 0.04, respectively) lower than the other groups of patients together. At last visit this difference was not significant. In B+ subjects, the WHI and HZ score at last visit were significantly (P = 0.04 for both) higher than at the first visit. B+ patients fully recover their body growth deficit compared with other groups of VUR subjects after medical and/or surgical therapy.

Height standard deviation scores (HSDS) and weight-for-height index (WHI) at diagnosis were evaluated in 156 children aged 2 months to 10.8 years (mean 3.7 years) with vesicoureteric reflux (VUR) and normal creatinine clearance, and in 156 age- and sex-matched healthy controls. Forty-three patients had bilateral VUR with scintigraphic signs of renal scarring (B SCAR+), 25 had bilateral VUR without renal scarring (B SCAR-); 40 had unilateral VUR with (U SCAR+) and 48 unilateral VUR without (U SCAR-) renal scarring. B SCAR+ patients had an average HSDS of -0.5 +/- 1.4 (SD) which was significantly (P = 0.02) below that of controls (0.05 +/- 1 HSDS) and an average WHI of 100.6% +/- 16% which was significantly (P = 0.007) below that of controls (108% +/- 12%); 14% of B SCAR+ patients had a height below -2 HSDS. B SCAR-, U SCAR+, and U SCAR- patients had heights near to O HSDS which was not different from that of controls, as well as WHI between 104% and 107.9%, which was not different from that of controls. HSDS and WHI were significantly (P = 0.00001) correlated in patients but not in controls. B SCAR-, U SCAR+, and U SCAR- patients are similar to healthy controls in weight and in height growth and have, on average, some excess weight as do the latter. In contrast, B SCAR+ subjects have a significant decrease of the relative height and normal WHI.

The pubertal growth spurt was followed for at least 3 years in 5 boys and 6 girls with chronic renal failure on conservative treatment. The peak height velocity averaged 8.6 cm/year (range 5.8-10.1 cm/year) in males and 8.2 cm/year (range 6.4-11.5 cm/year) in females. In none was the pubertal growth spurt below the 3rd percentile for chronological age. At the end of the follow-up period, all patients but 2 had stature within the normal limits of parental target. The relative variation of height averaged - 0.013 standard deviation scores per year. On the whole, the pubertal growth spurt was normal in subjects with chronic renal failure on conservative treatment.

Radius, ulna, short bones (RUS) and carpal (CARP) bone age were assessed in 26 steroid-dependent nephrotic boys after at least 1 year of alternate-day prednisone therapy, and in 26 age- and sex-matched control subjects. No significant difference in RUS bone age was found between patients and controls. CARP bone age of patients was significantly (P = 0.01) more retarded than in controls. In patients, CARP bone age delay was related to their relative height at the time of study (P = 0.01). We conclude that CARP bones are more prone to effects of steroids than are RUS bones. Therefore, CARP bone age may be a more sensitive tool in monitoring the effects of steroids on skeletal growth and maturation.

Vaccination against hepatitis B virus (HBV) was performed in 18 boys (aged 5.7 +/- 2.4 years) suffering from steroid-sensitive nephrotic syndrome (SSNS) and in a control group of 21 healthy boys (aged 5.6 +/- 3.8 years). The percentage of patients who responded to vaccination was significantly lower than the control group 1, 6, 8, 12, 18 and 24 months after the start of vaccination. The titre of antibodies to HBV surface antigen produced by responders at 6 and 24 months was significantly lower in patients than in the control group. Boys with SSNS have an impaired response to HBV vaccination.