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To investigate the clinical impact of BioFire FilmArray Gastrointestinal Panel (FGP) testing in real-life diarrhoeal episodes of hospitalised paediatric patients.Children hospitalised between October 2018 and September 2020 for whom stool specimens for FGP were submitted at the clinician's discretion were retrospectively observed. For each episode, demographics, clinical information and stool tests were collected.The clinical impact for each case was evaluated by changing the antibiotic prescription, following the result of the FGP testing. Out of 140 diarrhoeal episodes, 25 pathogens were found in 24 cases using conventional methods, whereas, FGP testing identified 75 pathogens in 56 cases (p 0.05). The pathogens more frequently identified by FGP testing were Campylobacter, Shigella, Rotavirus, Giardia lamblia and Cryptosporidium. The clinical impact of FGP testing was observed in 17/140 (12%) diarrhoeal episodes, and higher rates in previously healthy (19%) and solid organ-transplanted children (15%).We found that using FGP testing for hospitalised children with diarrhoeal episodes could increase pathogen identification and impact clinical decisions, especially in healthy and transplant patients.

This study aimed to evaluate short- and long-term outcomes of kidney transplantation over 37 years in a national referral center and compare outcomes between Israeli Jewish and Arab children. Data on 599 pediatric transplantations performed in 545 children during 1981–2017, including demographic parameters, kidney failure disease profile, and pre-transplant dialysis duration, were retrieved from our computerized database and patient files. Patient and graft survival were estimated using the Kaplan-Meier method. Twenty-year patient survival was 91.4% for live donor (LD) and 80.2% for deceased donor (DD) kidney recipients. Respective 10-year and 20-year graft survival rates for first kidney-only transplants were 75.2% and 47.0% for LD and 60.7% and 38.4% for DD grafts. Long-term graft survival improved significantly (p < 0.001) over the study period for recipients of both LD and DD allografts and reached 7-year graft survival of 92.0% and 71.3%, respectively. The proportion of DD transplantations was higher in the Arab subpopulation: 73.8% vs. 48.4% (p < 0.001). Graft survival was not associated with age at transplantation and did not differ between the Arab (N = 202) and Jewish children (N = 343). Median (IQR) waiting time on dialysis did not differ significantly between the Arab and Jewish children: 18 (10–30) and 15 (9–30) months, respectively (p Mann-Whitney = 0.312). Good and progressively improving long-term results were obtained in pediatric kidney transplantation at our national referral center, apparently due to expertise gained over time and advances in immunosuppression. Equal access to DD kidney transplant and similar graft survival were found between ethnic groups.

Bronchiolitis is an infectious disease, with no effective treatment. Music and Mozart's works specifically are known to have a positive effect on physiological parameters, while noise is considered harmful. We aim to evaluate the short-term effect of environmental noise detachment and/or music listening on the course of bronchiolitis in hospitalised children.This is a prospective, double-blinded randomised controlled trial. Patients were divided into three intervention groups: 1-Mozart's Sonata, 2-instrumental music, 3-silence. Music was heard via media players and soundproof headphones. Disease severity was evaluated before and after intervention using the Modified Tal score.Seventy music sessions were included in the analysis (Mozart n = 23, instrumental n = 22, silence n = 25). A one-point drop in the average bronchiolitis severity score was observed in all three groups from 7.1 (CI 95%, 5 to 9.2) to 6.1 (CI 95%, 4.3 to 7.9), p 0.001. No significant difference was found between the three groups with respect to change in the severity score before and after the intervention.Isolation from disturbing sounds heard in paediatric departments could be considered a simple non-invasive intervention in children hospitalised with bronchiolitis. Further studies are warranted to evaluate long-term effects of this intervention and the specific effect of music.

To describe our experience in treating children afflicted with orbital cellulitis.A retrospective analysis of hospital records of children afflicted with orbital cellulitis was conducted between 2005-2018. Clinical, laboratory and radiology characteristics as well as management, microbiological data, and outcomes were collected.Of the 94 patients, painful restriction of ocular motility was observed in 37.2% and proptosis in 34%, whereas, only 18% of the children presented with both classical signs. Children aged older than 9 years presented with markedly elevated inflammatory markers i.e., leukocytosis and C-reactive protein (CRP). Only a minority (12, 12.4%) required functional endoscopic sinus surgery.Our data support the general approach that orbital cellulitis should be initially managed conservatively with close monitoring; since, only a minority of patients require surgical intervention.

Summary Background Cytomegalovirus is a common congenital infection, with high morbidity after an early primary maternal infection. No effective means exist to prevent viral transmission to the fetus. We aimed to investigate whether valaciclovir can prevent vertical transmission of cytomegalovirus to the fetus in pregnant women with a primary infection acquired early in pregnancy. Methods This prospective, randomised, double-blind, placebo-controlled trial was done at the Infectious Feto-Maternal Clinic of Rabin Medical Center (Petach Tikvah, Israel). Pregnant women aged 18 years or older, with serological evidence of a primary cytomegalovirus infection acquired either periconceptionally or during the first trimester of pregnancy, were randomly assigned to oral valaciclovir (8 g per day, twice daily) or placebo from enrolment until amniocentesis at 21 or 22 gestational weeks. Randomisation was done separately for participants infected periconceptionally or during the first trimester and was done in blocks of four. Patients and researchers were masked to participant allocation throughout the entire study period. The primary endpoint was the rate of vertical transmission of cytomegalovirus. Statistical analyses were done according to per-protocol principles. The study was registered at ClinicalTrials.gov , NCT02351102 . Findings Between Nov 15, 2015, and Oct 8, 2018, we enrolled and randomly assigned 100 patients to receive valaciclovir or placebo. Ten patients were excluded, five from each study group; therefore, the final analysis included 45 patients (all singletons) in the valaciclovir group and 45 patients (43 singletons and two sets of twins) in the placebo group. In the valaciclovir group, including both first trimester and periconceptional infections, five (11%) of 45 amniocenteses were positive for cytomegalovirus, compared with 14 (30%) of 47 amniocenteses in the placebo group (p=0·027; odds ratio 0·29, 95% CI 0·09–0·90 for vertical cytomegalovirus transmission). Among participants with a primary cytomegalovirus infection during the first trimester, a positive amniocentesis for cytomegalovirus was significantly less likely in the valaciclovir group (two [11%] of 19 amniocenteses) compared with the placebo group (11 [48%] of 23 amniocenteses; p=0·020. No clinically significant adverse events were reported. Interpretation Valaciclovir is effective in reducing the rate of fetal cytomegalovirus infection after maternal primary infection acquired early in pregnancy. Early treatment of pregnant women with primary infection might prevent termination of pregnancies or delivery of infants with congenital cytomegalovirus. Funding None.

The current outbreak of COVID-19 raging globally is taking a heavy toll on the adult population, with a rapidly growing number of newly infected and critically ill patients. However, to date, mortality rate among children is low as they mostly suffer from a mild disease. Yet, other more routinely encountered childhood diseases do not stand still and continue to be the main share of pediatricians' everyday challenges. Here we describe a case series of routinely seen pediatric diseases with delayed diagnosis due to different aspects of what we call "Corona-phobia". These cases were easily collected within a 1-week period which implies that this is a more widespread phenomenon.In conclusion, this raises the possibility that measures taken to mitigate this pandemic may be more damaging to children overall than the virus itself. We believe that pediatricians as well as policy makers should take this important aspect into consideration. What is Known: • COVID-19 manifests as a mild disease in most children; however, children are an important reservoir and may become spreaders of the disease. • Social distancing and isolation are important tools in mitigating COVID-19 transmission. What is New: • This case series describes 7 cases with delayed diagnosis of every-day pediatric diseases that were not caused by COVID-19 but were highly influenced by different aspects of "Corona-phobia". • Our objective is to highlight the possibility that measures taken to mitigate this pandemic may lead to a substantial delay in the diagnosis of other non-COVID-19 related diseases.

Classical xanthinuria is a rare autosomal recessive metabolic disorder characterized by lack of xanthine dehydrogenase activity that often manifests as xanthine urolithiasis and risk of drug toxicity. Variants in the XDH or HMCS gene underlie classical xanthinuria type I and type II, respectively. Here we present two Israeli Arab families affected by type I xanthinuria in whom a c.2164A>T (Lys722Ter) variant in the XDH gene, previously reported in a Turkish family of Turkmen origin, was identified. Analysis of polymorphic markers surrounding the variant site revealed common haplotypes spanning 0.6 Mbp shared by all three, and 1.7 Mbp shared by two of the studied families. By applying Bayesian methods to a simple model of crossover events through generations in the chromosomes carrying the variant, the most recent common ancestor of these families was found to be 179 (95% credible limit 70) generations old. The estimated antiquity of the variant, the historical genealogy of the affected families and the history and present day dispersion of their people strongly suggest prevalence of this variant in the Afro‐Asian stone‐forming belt. As far as we are aware, this is a first report of an ancient variant causing xanthinuria with potential wide geographical dispersion.

We examined the clinical and physiological benefits of heated humidified high-flow nasal cannula (HHHFNC) in treating pediatric bronchiolitis in a general pediatric ward. Children aged 0 to 2 years, hospitalized with moderate to severe bronchiolitis, were connected to HHHFNC. Each child was evaluated at 4- to 10-hour intervals, both on and off the device, using the Wang et al Bronchiolitis Severity score and transcutaneous CO2 monitor. Sixteen children were included in the final analysis. The Bronchiolitis Severity score improved by 3 points during the first and second intervals ( P = .001). Transcutaneous CO2 values were reduced by an average 8.7 mm Hg ( P = .001). No adverse effects were noted in children connected to the device. The HHHFNC device used in a general pediatric ward setting served as a safe and efficacious tool in treating moderate to severe bronchiolitis. Immediate clinical and physiological improvement was observed and maintained 1 to 4 hours after disconnection from the device.

Aim We examined the impact of the COVID‐19 pandemic on how many children were admitted to Israel's largest tertiary paediatric hospital and why they were admitted. Methods Israel declared COVID‐19 a national emergency on 19 March 2020. This study examined daily hospital admissions to our three general paediatric wards during the COVID‐19 lockdown period from 20 March to 18 April 2020. These 258 admissions were compared with the 4217 admissions from the period immediately before this, 1 February to 19 March 2020, plus 1 February to 18 April in 2018 and 2019. We also compared why patients were admitted during the study period, and any pre‐existing conditions, with 638 children hospitalised during the same period in 2019. Results The mean number of daily hospitalisations during the COVID‐19 lockdown period was 8.6, which was 59% lower than the 20.9 recorded during the other three periods before COVID‐19. There was a significant decrease in the number of patients admitted with infectious (74%) and non‐infectious (44%) aetiologies from 2019 to 2020, and these occurred among patients with (58%), and without (55%), pre‐existing medical conditions. Conclusion The Israeli COVID‐19 lockdown had a dramatic effect on admissions to the paediatric wards of a tertiary hospital.

A significant drop was found in the number of hospitalizations due to bacterial infections among children during the first peak period of COVID-19 in Israel. There was a 77% decrease in serious bacterial infections, and ≥50% decrease in most types of bacterial infections, especially osteoarticular and skin infections, followed by pneumonia and ENT infections.

This study aimed to evaluate short- and long-term outcomes of kidney transplantation over 37 years in a national referral center and compare outcomes between Israeli Jewish and Arab children.Data on 599 pediatric transplantations performed in 545 children during 1981-2017, including demographic parameters, kidney failure disease profile, and pre-transplant dialysis duration, were retrieved from our computerized database and patient files. Patient and graft survival were estimated using the Kaplan-Meier method.Twenty-year patient survival was 91.4% for live donor (LD) and 80.2% for deceased donor (DD) kidney recipients. Respective 10-year and 20-year graft survival rates for first kidney-only transplants were 75.2% and 47.0% for LD and 60.7% and 38.4% for DD grafts. Long-term graft survival improved significantly (p0.001) over the study period for recipients of both LD and DD allografts and reached 7-year graft survival of 92.0% and 71.3%, respectively. The proportion of DD transplantations was higher in the Arab subpopulation: 73.8% vs. 48.4% (p0.001). Graft survival was not associated with age at transplantation and did not differ between the Arab (N = 202) and Jewish children (N = 343). Median (IQR) waiting time on dialysis did not differ significantly between the Arab and Jewish children: 18 (10-30) and 15 (9-30) months, respectively (p Mann-Whitney = 0.312).Good and progressively improving long-term results were obtained in pediatric kidney transplantation at our national referral center, apparently due to expertise gained over time and advances in immunosuppression. Equal access to DD kidney transplant and similar graft survival were found between ethnic groups.

Aim To present seven paediatric patients with appendicitis, all with late diagnosis resulting from different aspects of the fear from the current global COVID‐19 pandemic. Methods Cases were collected from three paediatric surgical wards. Comparison between complicated appendicitis rates in the COVID‐19 era and similar period in previous year was performed. Results All seven children presented with complicated appendicitis. Main reasons for the delayed diagnosis during the COVID‐19 era were parental concern, telemedicine use and insufficient evaluation. Higher complication rates were found during the COVID‐19 era compared to similar period in previous year (22% vs 11%, P‐value .06). Conclusion The fear from COVID‐19 pandemic may result in delayed diagnosis and higher complication rates in common paediatric medical conditions. We believe caregivers and healthcare providers should not withhold necessary medical care since delay in diagnosis and treatment in these routinely seen medical emergencies may become as big of a threat as COVID‐19 itself.

Acute urinary tract infection (UTI) is the most common bacterial infection in childhood. Although hyponatremia was described in ~ 2/3 of these children, its clinical significance is still unclear. Herein, we evaluated the prevalence and clinical implications of hyponatremia in children hospitalized with a UTI. Medical records of previously healthy children hospitalized between January 2011 and December 2016 with UTI were retrospectively reviewed. Patients (median age 5.5 months) were divided into two groups according to their sodium levels: normonatremia (Na ≥ 135 mEq/L) and hyponatremia (Na135 mEq/L). Hyponatremia diagnosed on admission was found in 114/219 children (49%). Hyponatremic patients experienced a more severe disease manifested by a longer hospital stay (3.8 vs 3.4 days, p = 0.003), a higher prevalence of abnormal findings on renal ultrasound (10 vs 2, p = 0.01), higher C-reactive protein (CRP) levels (8.6 vs 3.4 mg/dl, p =0.001), and a negative correlation between sodium levels and CRP (r = - 0.38, p0.001).Conclusion:Hyponatremia occurs frequently in children hospitalized with UTI and is associated with elevated inflammatory markers and a more severe disease course. What is Known: • Hyponatremia, one of the most common electrolyte abnormalities, occurs in approximately 1/3 of hospitalized children and in 2/3 of children with pyelonephritis. • In certain cases of various medical conditions, hyponatremia has been shown to correlate with disease severity. What is New: • Hyponatremia in hospitalized children with UTI correlates with elevated inflammatory markers and a more severe disease course.

Herein, we describe two members of one family who presented with recurrent episodes of hepatic failure, cerebellar ataxia, peripheral neuropathy, and short stature. Liver transplantation was considered. Whole-exome sequencing (Trio) revealed a synonymous variant in exon 4 of SCYL1:c.459C>T p. (Gly153Gly), which did not appear to affect the protein sequence. Computational prediction analysis suggested that this modification could alter the SCYL1 mRNA splicing processing to create a premature termination codon. The SCYL1 mRNAs in our patient’s lymphocytes were analyzed and aberrant splicing was found. Molecular analysis of family members identified the parents as heterozygous recessive carriers and the proband as well as an affected aunt as homozygous. Evidently, harmless synonymous variants in the SCYL1 gene can damage gene splicing and hence the expression. We confirmed that the pathogenicity of this variant in the SCYL1 gene was associated with spinocerebellar ataxia, autosomal recessive 21 (SCAR21). Other reported cases (accept one) of liver failure found in the SCYL1 variants resolved during childhood, therefore orthotropic liver transplantation was no longer appropriate.

Guidelines for bladder augmentation (BA) in kidney transplantation (KT) recipients are not well-defined. In our center, simultaneous BA with KT (BA-KT) is performed. We assessed transplantation outcomes of this unique extensive procedure.A case-control single center retrospective study. Transplantation outcomes were compared with those of KT recipients who did not need BA.Compared with 22 patients who underwent KT only, for 9 who underwent BA-KT, surgical complications and the need for revision in the early posttransplantation period were similar; early graft function was better: estimated glomerular filtration rate, 96.5 ± 17.1 versus 79.4 ± 16.6 mL/min at 0 to 6 months (P = 0.02); posttransplantation clean intermittent catheterization was more often needed: by 78% (7/9) versus 13% (3/22); and asymptomatic bacteriuria was more common: 100% versus 9% during the first 6 months (P0.001), 55% versus 9% (P = 0.02) and 66.6% versus 9% during the first and second years, respectively (P = 0.004). Urinary tract infection (UTI) incidence was also higher: 100% versus 23% during the first 6 months and 44% versus 9% during the second year posttransplantation. Graft function deteriorated significantly in the BA-KT group by the fifth posttransplantation year: estimated glomerular filtration rate was 47.7 ± 39.7 mL/min versus 69 ± 21.3 mL/min, with only 6 (66%) of 9 functioning grafts versus 100% in the KT only group. Causes of graft loss were noncompliance with drug therapy in 2 patients and recurrent UTIs in 2 patients.Excellent short-term outcome for simultaneous BA-KT is threatened by graft loss due to a high prevalence of UTIs and patient noncompliance with the demanding complex posttransplantation therapy.

From 1982 to 2011, 53 kidney transplantations (KT) for pediatric focal segmental glomerulosclerosis (FSGS) were recorded in the National Israeli Kidney Transplant Registry (NIKTR): 22—primary (1◦) FSGS, 25—proved/suspected genetic-secondary (2◦) FSGS, six lost/incomplete files/other. Half (56%) of 23 patients with 2◦ FSGS were Israeli-Arabs vs 29% of 1◦ FSGS KT recipients. 1◦ FSGS recurrence occurred in 64% (14/22) of 22 KT in 17 patients aged (median) 14 years vs 1/25 of 2◦ FSGS (P

PTA and anemia of CKD share a similar pathogenesis. However, PTA may be disproportionate to the reduction in the GFR. Data relating to the mechanism of PTA are scarce. We evaluated the erythropoiesis parameters in pediatric kidney recipients compared to children with CKD. A total of 100 patients (54 post-kidney TX, 46 with CKD) were enrolled in the single-center cohort study. GFR was found to be significantly lower in the CKD group (49.7±22.4 vs 72.9±28.5 mL/min/1.73 m², P

This study tested the hypothesis that during massive proteinuria, C-reactive protein (CRP) may be lost into the urine along with other proteins, making serum CRP (sCRP) level an unreliable marker of infection severity in nephrotic syndrome (NS). Children with active NS (n = 23) were compared with two matched control groups: patients with febrile non-renal infectious disease (n = 30) and healthy subjects (n = 16). Laboratory measurements included sCRP, urine protein, creatinine, IgG, and protein electrophoresis. Urinary CRP (uCRP) was measured by ELISA. Sixty-nine patients were enrolled: 23 patients with NS, 30 patients with non-renal febrile infectious diseases, and 16 healthy children. Median uCRP concentrations were 0 mcg/gCr (0–189.7) in NS, 11 mcg/gCr (0–286) in the febrile group, and 0 mcg/gCr (0–1.8) in the healthy group. The uCRP/creatinine ratio was similar in the NS and healthy groups (p > 0.1) and significantly higher in the febrile group than the other two groups (p

Adrenal Calcifications in an Infant A 4-month-old girl was hospitalized with failure to thrive, hepatosplenomegaly, anemia, and hyperlipidemia. Radiography revealed calcification of both adrenal glands. A diagnosis of lysosomal acid lipase deficiency was made.

Decreased production of erythropoietin (EPO) is a major cause of anemia associated with chronic kidney disease (CKD). Treatment with recombinant human EPO (rHuEPO) improves patients’ quality of life and survival; however, there is a marked variability in response to rHuEPO. At present, no available laboratory test is capable of evaluating responsiveness to EPO treatment. The aim of the present study was to use an in vitro bioassay to estimate the effect of uremic environment on EPO-dependent erythroid cell proliferation. EPO-dependent human erythroleukemia cells (UT-7) were incubated with exogenous EPO (2 u/ml) and sera obtained from 60 pediatric patients (aged 1–23 years). Three groups were studied: (1) 12 children on dialysis (4 peritoneal, 8 hemodialysis); (2) 28 patients with CKD 1–5 (not on dialysis), and (3) 20 healthy children. Sera from dialysis patients inhibited UT-7 cell growth compared to the CKD group and healthy controls at 48 h (p = 0.003 and p = 0.04, respectively) and 72 h of culture (p = 0.02 and p = 0.07, respectively). In 18 patients treated with rHuEPO, a significant inverse correlation was found between the EPO resistance index and cell proliferation at 48 h (p = 0.007, r = − 0.63) and 72 h (p = 0.03, r = − 0.52). Our findings support the presence of erythropoiesis inhibitory substances in uremic sera. EPO/EPO-R-dependent mechanisms may play a role in inhibiting erythropoiesis. The in vitro bioassay described herein may serve as an indicator of rHuEPO responsiveness which may encourage further investigation of underlying mechanisms of EPO resistance.

Several studies link the pathogenesis of nephrotic syndrome to tumor necrosis factor-alpha (TNFα). However, data on the serum TNFα level in children with nephrotic syndrome are sparse.To investigate serum TNFα levels and the effect of steroid therapy in children with nephrotic syndrome.A prospective cohort pilot study of children with nephrotic syndrome and controls was conducted during a 1 year period. Serum TNFα levels were measured at presentation and at remission, or after a minimum of 80 days if remission was not achieved.Thirteen patients aged 2-16 years with nephrotic syndrome were compared with 12 control subjects. Seven patients had steroid-sensitive and six had steroid-resistant nephrotic syndrome. Mean baseline serum TNFα level was significantly higher in the steroid-resistant nephrotic syndrome patients than the controls (6.13 pg/ml vs. 4.36 pg/ml, P = 0.0483). Mean post-treatment TNFα level was significantly higher in the steroid-resistant than in the steroid-sensitive nephrotic syndrome patients (5.67 pg/ml vs. 2.14 pg/ml, P = 0.001). In the steroid-resistant nephrotic syndrome patients, mean serum TNFα levels were similar before and after treatment.Elevated serum TNFα levels are associated with a lack of response to corticosteroids. Further studies are needed to investigate the role of TNFα in the pathogenesis of nephrotic syndrome.

C reactive protein (CRP) is an acute phase reactant that primarily produced by hepatocytes yet may be locally expressed in renal tubular cells. We assessed the association of CRP and the risk for chronic kidney disease (CKD) development. Historical prospective cohort study was conducted on subjects attending a screening center in Israel since the year 2000. Subjects with an estimated GFR (eGFR) above 60 ml/min/1.73 m2 at baseline were included, and high sensitive (hs) CRP levels as well as eGFR were recorded for each visit. Follow up continued for at least 5 years for each subject until 2013. Risk for CKD at end of follow up was assessed in relation to mean hs-CRP levels of each subject. The confounding effects of other predictors of CKD were examined. A logistic regression model treating CRP as a continuous variable was further applied. Out of 4,345 patients, 42 (1 %) developed CKD in a mean follow up of 7.6 ± 2 years. Elevated levels of CRP were associated with greater risk for CKD (crude OR 4.17, 95 % CI 1.46–11.89). The OR for the association of CRP with CKD when controlling for age and gender was 5.2 (95 % CI 1.7–16.2). When controlling for established renal risk factors, elevated CRP levels remained significantly associated with greater risk for CKD (OR 5.42, 95 % CI 1.76–16.68). When applying logistic regression models treating CRP as a continuous variable, for patients with diabetes mellitus (DM), hypertension (HTN) or eGFR between 60–90 ml\min\1.73 m2, the predictive role of CRP for CKD was highly significant. Elevated CRP level is an independent risk factor for CKD development. In patients with DM, HTN or baseline eGFR between 60–90 ml\min\1.73 m2 its predictive role is enhanced.

Background Cytomegalovirus (CMV) is the most common cause of congenital infection in humans. The highest risk of fetal injury follows a maternal primary infection early in pregnancy. Despite the potential for severe fetal injury, to date there are no proven means to prevent viral transmission. Valacyclovir is an antiviral drug proven effective in decreasing the risk for CMV infection among transplant recipients. Valacyclovir is safe for use in pregnancy, and concentrates in the amniotic fluid without accumulating. A dose of 8 g/day creates therapeutic drug levels in the amniotic fluid and fetal blood. Methods This is a randomized, double-blind, placebo-controlled study comprising pregnant women with serologic evidence of primary CMV infection during the periconceptional period and first trimester. After informed consent, patients were randomly assigned to a treatment group (8 g/day of Valacyclovir) or control group (placebo). Treatment was initiated at the time of serological detection, and continued until amniocentesis. The primary endpoint was the rate of vertical transmission of CMV—determined by amniotic fluid CMV PCR. Secondary endpoints included evidence of symptomatic congenital CMV infection—in utero or postnatally. Results One hundred women were recruited, 90 were included in the data analysis; 45 patients received Valacyclovir and 45 placebo. There were 2 twin pregnancies, and therefore 92 amniocentesis Amongst the Valacyclovir group, 5 (11.1%) amniocentesis were positive for CMV, compared with 14 (29.8%) in the placebo group (P GLMM = 0.03), corresponding with an odds ratio of 0.29 (95% CI: 0.09–0.90) for vertical CMV transmission. Amongst patients infected during the first trimester, a positive amniocentesis for CMV was significantly (P = 0.02) less likely in the Valacyclovir arm (2/19) compared with placebo (11/23). No significant differences (P = 0.91) in CMV-positive amniocentesis were observed between study arms amongst patients infected periconceptionally. Conclusion Valacyclovir at a dose of 8 g/day is effective in reducing the rate of fetal CMV infection following early maternal primary infection during pregnancy. The drug reduces the rate of fetal infection by 71%. Disclosures All authors: No reported disclosures.

The incidence of post-infectious glomerulonephritis (PIGN) has decreased over the last decades. As a result, recent epidemiological data from industrialized countries are scarce.To evaluate patterns of PIGN in children and detect possible predictors of disease severity.We collected clinical and laboratory data of patients with PIGN admitted to Schneider Children's Medical Center during 1994-2011. Diagnostic criteria included presence of hematuria with/without other features of nephritic syndrome along with hypocomplementemia and/or microbiological/serological evidence of streptococcal infection. Patients with other diseases (systemic lupus erythematosus, vasculitis, etc.) were excluded from the study.A total of 125 patients with a mean age of 5.8 ± 3.3 years (range 1.5-17.6), of whom 16% were3 years, matched the study criteria. Presenting features included hypertension in 103 (82.4%) patients, azotemia in 87 (70.2%), fever in 49 (40/6), and elevated C-reactive protein in 75 (81.5%). Isolated macrohematuria was found in 21 (16%). Full-blown nephritic syndrome was diagnosed in 51 patients (41.1%) and 28 (22.9%) had nephritic syndrome with nephrotic-range proteinuria. Depressed C3 complement levels were associated with the presence of nephritic syndrome (OR 0.73, 95% CI 0.60-0.88, P = 0.001) as well as older age (OR 1.24, Cl 1.08-1.43, P = 0.001). At last follow-up (mean 42 months) all examined patients (100 of 125) had normal renal function, 6 had hypertension, and 1 had proteinuria.PIGN remains an important cause of glomerular disease in children and may affect very young patients. Nephrotic-range proteinuria with hypoalbuminemia seems to be more frequent than previously reported. Hypocomplementemia is associated with a more severe disease course, namely, azotemia and nephritic syndrome.

PTLD is the most common malignancy in pediatric kidney-transplant recipients. We examined the prevalence, clinical features, and outcome of PTLD in Israel. Twelve (4.4%) of 272 pediatric (

BACKGROUND In recent years, liver transplantation (LT) has become a well-accepted therapeutic modality for children with end-stage liver disease, with transplantation surgery being performed at a younger age. Human herpes virus 6 (HHV-6) infection occurs in most children within the first 2 years of life, therefore, data on primary HHV-6 infection in pediatric liver transplant recipients is scarce. OBJECTIVE To describe the course of primary HHV-6 infection after pediatric LT. METHODS Medical files, between the years 2015-2016, of post-LT pediatric patients with suspected primary HHV-6 infection were reviewed. Clinical and laboratory data for enrolled cases were evaluated. Primary infection was defined as DNAemia in children who were seronegative prior to transplantation or seroconversion from negative to positive IgG posttransplantation. RESULTS Four cases of primary HHV-6 (type B) infection were identified among the 26 children who had undergone LT at our center during the study period. All patients were

Deferasirox is a recently approved oral iron chelator for treatment of patients with transfusion-related iron overload. Although renal function disturbances were recognized, proximal renal tubulopathy was not addressed in published safety reports for deferasirox. Although subclinical proximal tubulopathy was described in β-thalassemia homozygotes, overt Fanconi kidney is not an established disease complication. We describe 4 cases out of 50 children and adults with transfusion-dependent β-thalassemia, treated with deferasirox for iron overload, who developed clinically significant Fanconi syndrome. Three had concomitant infectious events; the fourth case was entirely spontaneous. In addition, all 4 patients were moderately to well chelated. Cessation of deferasirox resulted in prompt recovery. We propose the necessity for diligent monitoring for proximal tubule nephropathy, possibly related to infectious events, during treatment with deferasirox.

Krause I, Snir M, Cleper R, Fraser A, Kovalski Y, Axer Siegel R, Bar-Nathan N, Davidovits M. Ocular complications in children and adolescents following renal transplantation. Pediatr Transplantation 2010: 14: 77–81. © 2009 Wiley Periodicals, Inc. Abstract: Ocular complications after renal transplantation are common in adults. Nevertheless, data regarding these complications in children are insufficient. The purpose of the present study was to assess ocular morbidity in pediatric renal graft recipients. A retrospective observational study of 71 patients aged 11.2 ± 5.5 yr was conducted. Mean duration of follow-up was 5.6 ± 3.5 yr. A total of 16 ocular complications were found in 12 (17%) of the patients. Three patients suffered from more than one complication. Cataract was the most common finding (six patients, 8.4%) followed by swollen disk and hypertensive retinopathy in four patients (5.7%) each and increased intra-ocular pressure in two patients (3%). Mean time interval between transplantation and occurrence of first abnormal ocular finding was 37 ± 34.5 months. The follow-up time was significantly longer in patients with ophthalmological problems than in those without complications (7.8 yr vs. 5.2 yr, p

Renovascular hypertension in children is usually asymptomatic and diagnosed incidentally. Behavioral changes have not yet been well recognized as a part of the clinical spectrum of renovascular disease in children. We surveyed all children diagnosed with renovascular hypertension in our institute over a 15-year period. Eleven children were identified, of whom five (45%) had abnormal behavior, which had preceded the diagnosis of hypertension by 3-12 months. The symptoms included restlessness, sleep disturbances, temper tantrums, hyperactivity, aggressive behavior and attention deficit. In three children all behavioral symptoms disappeared following blood pressure normalization, and, in the other two a significant improvement was noted. It was concluded that behavioral symptoms may be a common and early manifestation of renovascular hypertension. Awareness of this association may bring about earlier diagnosis of the disease and prevent end-organ damage as well as unnecessary investigations for behavioral abnormalities.

Background: Children with renal osteodystrophy (ROD) may develop severe angular deformities of the limbs. Various methods, both medical and surgical, have been described for correction of these deformities, but a literature search showed only 1 child previously treated by the Ilizarov method. The purpose of this study was to characterize the deformities found in our group of patients and to describe our experience in treating these patients with the Ilizarov method. Methods: Correction of angular deformity by the Ilizarov method was performed on 8 limb segments in 5 patients with ROD. Mean age was 14.9 years. Two patients were on hemodialysis, and 3 had functioning kidney grafts. Surgery was deferred until stabilization of metabolic parameters. Results: There was 1 varus and 7 valgus deformities. Preoperative coronal deformity averaged 29 degrees (18-38 degrees). The Ilizarov apparatus was used in all cases. Correction time averaged 23 days (20-28 days). The time from completion of correction to frame removal averaged 71 days (48-113 days). There were no changes in metabolic parameters or frequency of hemodialysis throughout the treatment. Restoration of a normal mechanical axis was achieved in 4 of the 5 patients. One case failed due to intraarticular instability. There were no major complications. Minor complications included pin tract infections, which responded to antibiotic treatment, and premature consolidation in 1 case. Follow-up averaged 6.5 years (1-10 years). The alignment obtained at surgery was maintained in all 4 patients, and they are functional and symptom-free. The patient for whom the surgery failed remains wheelchair-bound. Conclusions: The Ilizarov method was found to be safe and effective for correction of malalignment due to ROD. Optimization of metabolic parameters is essential before surgery and throughout correction. The procedure is contraindicated in patients with significant intraarticular knee pathology.

Use of kidneys from pediatric donors has been associated with worse outcome. We review our 20-yr experience using pediatric kidneys as single grafts in children and adult recipients. Charts review of 29 recipients, transplanted between 1986 and 2005, who received a graft from a donor

Despite significant technical improvements, hemodialysis in infants with end-stage renal disease (ESRD) is still associated with significant morbidity and mortality. The files of patients weighing less than 15 kg with ESRD who were treated with hemodialysis at our institute between 1995 and 2005 were reviewed for background and treatment characteristics, morbidity and outcome. The study group included 11 patients aged 7-75 months (mean 34.2 months) weighing 7.2-14.9 kg (mean 10.9 kg). Mean duration of dialysis was 11.3 months. Vascular access posed the major problem. Ten patients were dialyzed through a central venous cuffed catheter and one through an arteriovenous fistula. An average of three different vascular accesses was required per patient (range 1-9). Mechanical difficulties were the most common cause of central-line removal (56.5%), followed by infections (15.6%). Major complications causing significant morbidity were intradialytic hemodynamic instability, hyperkalemia, coagulation within the dialysis set, anemia, hypertension, inadequate fluid removal, and recurrent hospitalizations. Analysis of outcome revealed that eight patients underwent successful transplantation, one returned for hemodialysis after 4.5 years due to graft failure, and two died. Hemodialysis is a suitable option for low-weight pediatric patients with ESRD awaiting transplantation when performed in highly qualified centers.

Patients on long-term hemodialysis undergo multiple interventions, including insertion of central catheters and arteriovenous anastomoses for creation of vascular access. The need for high-flow vessels to maintain hemodialysis efficiency leads to wear on the central veins and consequent stenosis and occlusion. In addition to local signs of impaired venous drainage, abnormal venous flow patterns involving the upper chest, face, and central nervous system might develop. We describe the first pediatric case of devastating intracranial hypertension presenting with visual loss in the eye contralateral to a high-flow vascular access in a patient on long-term hemodialysis. The literature on this rare complication of hemodialysis is reviewed.

Objective: To examine the feasibility and effectiveness of intradialytic parenteral nutrition (IDPN) in children on hemodialysis. Design: Prospective experimental study with a single intervention group. Setting: A pediatric hemodialysis unit. Subjects: Four malnourished children on hemodialysis (3 girls and 1 boy) 4 to 18 years of age were studied during a period of 1 year. Intervention: IDPN, which is composed of amino acids (8.5% solution), glucose (as 10% to 15% dextrose), and 20% fat emulsion, was administered at every dialysis session (3 times a week, during 4 hours each time) for 7 to 12 weeks. Main outcome measure: Oral caloric intake (evaluated by using a 3-day diet history), dry weight (weight after dialysis), body mass index, percent ideal body weight, total lymphocyte count, and serum levels of albumin before, immediately after cessation of IDPN, and 3 months after cessation of IDPN. Results: Oral caloric intake increased markedly after IDPN administration, from 5 to 63 kcal/kg/d (mean, 33 kcal/kg/d) before IDPN administration to 35 to 177 kcal/kg/d (mean, 86 kcal/kg/d) at the time of cessation. Weight did not change during the treatment period but it did increase from 9.5 to 36.4 kg (mean, 25 kg) to 11 to 39 kg (mean, 26.7 kg) 3 months later. Percent ideal body weight increased from 73% to 88% (mean, 78.5%) to 79% to 90% (mean, 85.1%), and body mass index increased from 12.2 to 15 kg/m2 (mean, 13.5 kg/m2) to 13.4 to 15.5 kg/m2 (mean, 14.6 kg/m2). Total lymphocyte count increased from 538 to 2,041 cells/mm3 (mean, 1,403 cells/mm3) to 724 to 2,884 cells/mm3 (mean, 2,066 cells/mm3). Plasma levels of albumin increased in 1 patient but remained unchanged in others. Conclusion: Short-term IDPN treatment may serve as a safe and effective nutritional intervention in malnourished children on hemodialysis. © 2002 by the National Kidney Foundation, Inc.

Cross-sectional studies have long suggested that renal function declines with age. Longitudinal studies regarding this issue are limited.We retrospectively analyzed a database of subjects attending a screening center in Israel between the years 2000-2012. Only subjects with normal estimated glomerular filtration rate (eGFR) were included. eGFR was assessed consequently at 5 or more yearly visits. The rate of decline in GFR with age was assessed in healthy subjects and in subjects with comorbidities.The cohort included 2693 healthy subjects and 230 subjects with different comorbidities. Mean (±standard error) annual rate of decline in eGFR in healthy subjects was 0.97 ± 0.02 ml/min/year/1.73 m(2). This decline increased significantly from 0.82 ± 0.22 in age-group 20-30 years to 0.84 ± 0.08, 1.07 ± 0.08 and 1.15 ± 0.12 ml/min/year/1.73 m(2) in age groups 31-40, 41-50 and 50 years and older respectively (p0.001). No correlation was found between the annual decline in eGFR and body mass index. In subjects with hypertension, diabetes mellitus, impaired fasting glucose or combined comorbidity the decline in eGFR was 1.12 ± 0.12, 0.77 ± 0.16, 0.85 ± 0.17, and 1.18 ± 0.26 ml/min/year/1.73 m(2) respectively.This large longitudinal study provides new data on the decrease in eGFR with age. Accurate prediction of the natural rate of GFR decline might be used to distinguish between normally aging kidneys and those with chronic disease. This approach could avoid unnecessary diagnostic procedures in the former and facilitate appropriate treatment in the latter.

Background Cryptosporidium parvum is a common cause of diarrhea. In immunocompetent individuals, spontaneous recovery is the rule. In immunocompromised patients, it may cause a serious disease. Data on cryptosporidiosis in children after solid organ transplantation are few. We report on 6 pediatric solid organ recipients with gastroenteritis caused by Cryptosporidium. Patients and methods All episodes of gastroenteritis in solid organ transplant recipients hospitalized in Schneider Children's Medical Center from January 2008 to August 2011 were identified. Data on the episodes with positive staining for Cryptosporidium antigen in stool were reviewed. Results Fifty-seven episodes of gastroenteritis were recorded. In 6 (11%) patients (4 kidney recipient, 1 liver and kidney recipient and 1 heart transplant recipient) Cryptosporidium antigen was detected in stool. Mean age at transplantation was 3.7 ± 2 years, mean time between transplantation and cryptosporidial disease was 39 ± 53.9 months. Symptoms included prolonged diarrhea, fever, abdominal pain and weight loss. Mean duration of symptoms before diagnosis was 10.5 ± 8.7 days. In 5 children, kidney function deteriorated, blood concentrations of tacrolimus increased in 5 patients and abnormal values of liver enzymes were detected in 4 patients. All patients were hospitalized and received intravenous fluid replacement and were treated with nitazoxanide for 5-21 days. Two patients had recurrence of symptoms after short course (5 days) therapy. All patients recovered eventually from the disease. Conclusion Cryptosporidium should be routinely tested in solid organ transplant recipients with diarrhea. Delay in initiation of treatment can result in serious complications including acute renal failure. Long-term therapy with nitazoxanide (at least 14 days) may facilitate recovery.

PTLD is the most common malignancy in pediatric kidney-transplant recipients. We examined the prevalence, clinical features, and outcome of PTLD in Israel. Twelve (4.4%) of 272 pediatric (19 yr) kidney-transplant recipients retrieved from a search of the NIKTR for 1991-2008 had acquired PTLD at a median of 3.2 yr post-transplantation. PTLD-affected patients were younger at transplantation (4.2 vs. 12.5 yr, p = 0.02), had a higher rate of OKT3 therapy for acute rejection (25% vs. 4%, p = 0.015), and 5/12 were EBV-seropositive at transplantation. Graft dysfunction was the presenting sign in six (50%). PTLD was predominantly abdominal (83%) and B-cell type (67%); T-cell PTLD occurred exclusively in EBV-seropositive patients. Treatment consisted of immunosuppression cessation (6/12, 50%), antiviral agents (7/12, 58%), anti-CD20 monoclonal antibodies (4/12, 33%), and chemotherapy (6/12, 50%). Survival was 100% in the EBV-naïve patients and 40% in the EBV-seropositive patients. Graft loss occurred in three of eight survivors (37.5%). PTLD-associated mortality risk was older age: 11.2 vs. 3.4 yr, longer dialysis: 15 vs. 6.5 months, T-cell type disease (75%), later PTLD onset: 6.35 vs. 1.9 yr post-transplantation and era of transplantation (43% mortality before vs. 20% after 2001). Pretransplantation EBV-seronegative status might confer a survival benefit with early detected PTLD. EBV-seropositive patients are at risk for aggressive late-onset lethal PTLD.

Background. Non-autoimmune hypothyroidism has been reported in children with congenital nephrotic syndrome. The hypothyroid state was attributed to massive prolonged thyroid hormone loss. However, this endocrine abnormality has not been reported in steroid-resistant nephrotic syndrome (SRNS) despite similar long-standing proteinuria. Method. We describe all the patients with SRNS in our clinic’s follow-up who developed non-autoimmune hypothyroidism. Results. Five children aged 3-11 years at diagnosis of SRNS and followed for 5-42 months developed hypothyroidism (depressed free thyroxin and elevated thyrotropin levels) without evidence of autoimmune thyroiditis. The diagnosis of hypothyroidism was not temporarily related to disease duration or renal function. The disease was resistant to all therapies, renal function deteriorated in all the patients within 1.5-14.5 years from diagnosis. Despite thyroxine treatment and a decline in renal function, thyroid hormone level normalized only after reaching end stage renal disease (ESRD) and hemodialysis start. Nephrotic syndrome recurrence after kidney transplantation (in three patients with focal segmental glomerulosclerosis) was not accompanied by recurrent hypothyroidism. Conclusion. It is our impression that non-autoimmune hypothyroidism is a potential significant complication of SRNS, and should be actively sought for especially in cases with renal function deterioration. Hypothyroidism usually resolved when these patients reach ESRD. The incidence and pathogenesis of this condition require further study.

Hyponatremic hypertensive syndrome (HHS) is characterized by unilateral renal artery stenosis with secondary hypertension and glomerular and tubular dysfunction due to hyperfiltration and activation of the renin-angiotensin system (RAS).We describe four children with HHS. All presented with polyuria and polydipsia, electrolyte disturbances, metabolic alkalosis, variable tubular dysfunction, and nephrotic range proteinuria along with hypertension. Interestingly, in one patient, glomerular and tubular abnormalities preceded the development of hypertension. All symptoms resolved after the underlying renal ischemia was corrected by percutaneous angioplasty.Hyponatremic hypertensive syndrome may be more common in children than previously thought. Clinicians should be alert of the signs and symptoms because cure is possible with timely diagnosis and treatment.

Acute renal failure (ARF) is a common complication in critically ill children. It is known as an important predictor of morbidity and mortality in this population. Data on the factors affecting the choice of renal replacement therapy (RRT) modality and its impact on mortality of children with ARF are limited.We retrospectively studied 115 children with ARF necessitating RRT during the period 1995-2005 to evaluate the effect of several prognostic factors as well as RRT type on their immediate outcome.The data collected from charts included demographics, primary disease, accompanying medical conditions, use of vasopressor support, indications for dialysis, RRT modality, and complications of dialysis. Categorical variables were analyzed using chi-square or Fisher's exact tests. Variables associated with mortality (P0.1) at the univariable level were studied by a multivariable logistic regression model.The most common cause of ARF was congenital heart disease (n=75). RRT modalities included peritoneal dialysis (PD) (n=81), hemodialfiltration (HDF) (n=31) and intermittent hemodialysis (IHD) (n=18). Median RRT duration was 4 days (range 1-63 days). Overall mortality was 52.2%. IHD was associated with the best survival rate (P0.01 vs. PD and HDF), while children treated with HDF had the worse outcome. Hemodynamic instability and systemic infections were associated with greater mortality, but the rate of these complications did not differ between the study groups.Our results suggest that IHD when applied to the right patient in an appropriate setting may be a safe and efficient RRT modality in children with ARF. Randomized prospective trials are needed to further evaluate the impact of different RRT modalities on outcome in children with ARF.

Peritonitis is a major complication of chronic peritoneal dialysis therapy. It is recommended that each center monitor infection rates in order to define the local microbiological profile and implement an appropriate empiric antibiotic regimen.To analyze the microbiologic profile of peritonitis in our pediatric dialysis unit and identify local predisposing factors.In this retrospective study we reviewed the files of children treated with chronic PD during the 10 year period 1997-2007.Eighty peritonitis episodes were recorded in 29 children (20 male, 9 female) aged 0.1-18.5 years (median 11.75) treated with peritoneal dialysis for 6-69 months (median 19) for a total of 578 patient-months. The annual peritonitis rate was 1.66/patient. The main pathogens were coagulase-negative Staphyloccocus (32.5%) and Pseudomonas spp. (16%), which were also cultured in most cases (64-69%) from the exit site during the 3 months preceding peritonitis. No peritonitis occurred in 31% of the patients (median age 12.5 years). All patients less than 5 years old had at least one peritonitis episode. Contaminating conditions (gastrostomy, enuresis, diaper use), found in 44% of the study group, and first infection within 6 months from starting PD were significantly associated with an increased peritonitis rate (P = 0.01, P = 0.009, respectively). Recurrent peritonitis led to a switch to hemodialysis in 18% of patients. There were no deaths.The risk factors for peritonitis in our study were: first infection within less than 6 months from starting treatment, Pseudomonas exit-site colonization, and contaminating conditions (gastrostomies, diaper use, enuresis). These susceptible subgroups as well as very young age (5 years) at starting PD should be especially targeted during training of caregivers and follow-up to prevent later complications.

Background. Failed renal allografts left in situ may cause inflammation presenting as graft intolerance syndrome (GIS).Therearenosufficientdataregardingclinicalcourse and treatment options of GIS in paediatric patients. Methods. A retrospective study of all children with failed renal allografts treated in Schneider’s Children Medical Center of Israel during a 10-year period was conducted. Diagnosis of GIS was based on clinical criteria and persistence of renal perfusion according to radio-isotopic scan. Results. Twenty children with failed renal allografts were studied. The mean age at transplantation was 10.3 ± 4.9 years. The mean graft survival was 2.9 ± 2.5 years. Two grafts were removed immediately due to vascular complications. Of the 18 patients with transplants remaining in situ, 11 (61%) developed GIS within 2.7 ± 2.1 months after restarting dialysis. GIS manifestations included fever (91%), local tenderness (82%), hypertension (73%), abdominal pain (64%), macroscopic haematuria (27%), pulmonary congestion (27%) and enlargement of the graft (18%). Laboratory findings included anaemia, hypoalbuminaemia and elevated ESR and CRP. Three patients were successfully treated with indomethacin and/or prednisone. In one patient the graft was surgically removed due to suspected post-transplantation lymphoproliferative disorder. Seven patients underwent percutaneous embolization of the graft, and in six patients a complete resolution of symptoms occurred within 32.2 ± 45 days. Complications included abscess and retinal artery thrombosis. Six patients were successfully re-transplanted, three are still on haemodialysis and two died of causes unrelated to GIS. Conclusions. GIS may be common among children with failed renal allografts. Percutaneous embolization of the graft seems effective and safe. Further studies are needed to evaluate late outcome of paediatric patients with GIS.

A 12-year-old girl with recent history of pseudotumor cerebri developed severe postural headache due to intracranial hypotension after lumbar puncture. Meningeal enhancement and thickening were demonstrated on magnetic resonance imaging. Repeated imaging 3 months later disclosed no abnormalities. This is the first report of a child with evident meningeal enhancement on magnetic resonance imaging related to lumbar puncture.

Glomerular and tubular function of transplanted kidneys were assessed in 46 children aged 15.7 +/- 4.6 yr, 4.2 +/- 2.8 yr after renal transplantation. There were 34 cadaveric, and 12 living-related donors. Twelve patients (26%) had acute episodes (acute tubular necrosis, rejection, or urinary tract infection) during follow-up. All patients were on triple immunosuppression. The mean serum creatinine was 1.5 +/- 0.6 mg/dL. Creatinine clearance (Ccreat) calculated from a 24-h urine collection was 48.0 +/- 19.7 mL/min/1.73 m(2), and that estimated from the Schwartz formula, 61.0 +/- 22.5 mL/min/1.73 m(2). A positive correlation was found between the calculated and estimated clearances. Mean urine concentrating ability was 487 +/- 184 mOsmol/kg, with a value lower than 400 mOsmol/kg in 35% of patients. There was a positive correlation between urine osmolality and estimated Ccreat. Metabolic acidosis (bicarbonate

Seven patients aged 13 to 17.5 years developed acute renal failure after treatment with a variety of non-steroidal anti-inflammatory drugs (NSAID): naproxen, diclofenac, ibuprofen, dipyrone and paracetamol. Six of the patients used more than one kind of NSAID. None of the patients had previous history of renal disease or concomitant treatment with other drugs. The time interval between NSAID administration to the emergence of symptoms ranged from 1 to 4 days. The most common presenting symptoms were flank pain (4 patients), abdominal pain (3 patients) and vomiting (3 patients). All patients had normal urine output. Microscopic hematuria and proteinuria were found in 5 patients and leukocyturia in 2. Serum creatinine ranged from 1.3 to 8.3 mg% at presentation. Kidney biopsy was performed in 3 patients and showed findings consistent with mild interstitial inflammation in 1 patient, and normal renal tissue in 2. All patients were treated with intravenous fluids, 1 received corticosteroids. Renal function completely normalized in all patients within 7 to 16 days.