2016, Vol 12, No 1
Averting the legacy of kidney disease – focus on childhood
Pediatr Med Rodz 2016, 12 (1), p. 10–19
DOI: 10.15557/PiMR.2016.0001

World Kidney Day 2016 focuses on kidney disease in childhood and the antecedents of adult kidney disease that can begin in earliest childhood. Chronic kidney disease in childhood differs from that in adults, as the largest diagnostic group among children includes congenital anomalies and inherited disorders, with glomerulopathies and kidney disease in the setting of diabetes being relatively uncommon. In addition, many children with acute kidney injury will ultimately develop sequelae that may lead to hypertension and chronic kidney disease in later childhood or in adult life. Children born early or who are small-for date newborns have relatively increased risk for the development of chronic kidney disease later in life. Persons with a high-risk birth and early childhood history should be watched closely in order to help detect early signs of kidney disease in time to provide effective prevention or treatment. Successful therapy is feasible for advanced chronic kidney disease in childhood; there is evidence that children fare better than adults, if they receive kidney replacement therapy including dialysis and transplantation, while only a minority of children may require this ultimate intervention. Because there are disparities in access to care, effort is needed so that those children with kidney disease, wherever they live, may be treated effectively, irrespective of their geographic or economic circumstances. Our hope is that World Kidney Day will inform the general public, policy makers and caregivers about the needs and possibilities surrounding kidney disease in childhood.

Keywords: chronic kidney disease, paediatric nephrology, paediatrics, congenital anomalies of the kidney and urinary tract (CAKUT), developmental origins of health and disease (DoHAD)
Idiopathic hypercalciuria
Pediatr Med Rodz 2016, 12 (1), p. 22–27
DOI: 10.15557/PiMR.2016.0002

Idiopathic hypercalciuria is one of the most commonly diagnosed metabolic disorders in paediatric and adult patients with urolithiasis. Increased urinary calcium excretion is defined as >4 mg/kg per day. The degree of hypercalciuria can be also estimated based on calcium/creatinine ratio, which is calculated from the morning urine sample. Symptoms of hypercalciuria are nonspecific and may include e.g. abdominal pain, haematuria, recurrent urinary tract infections, leukocyturia or dysuria. The disorder primarily leads to formation of urinary deposits. Three types of hypercalciuria, i.e. absorptive, renal and resorptive, were distinguished based on Pak’s test. The pathogenesis of idiopathic hypercalciuria probably involves both genetic and environmental factors. It is likely that the disease is polygenic in nature, with a varying expression of multiple genes among patients. It is believed that patients with idiopathic hypercalciuria have an increased number of vitamin D receptors or show higher susceptibility to this compound. Diet is another factor affecting the degree of hypercalciuria and the dynamics of urolithiasis. It also seems that adequate vitamin D supplementation can reduce the predisposition to form calcium crystal deposits. It is increasingly postulated that absorptive, renal and resorptive types of hypercalciuria represent different, alternately occurring manifestations of the same disease. Furthermore, it should be emphasised that urolithiasis and idiopathic hypercalciuria are associated with decreased bone density, which is observed in all patient populations, including children.

Keywords: hypercalciuria, urolithiasis, urinary tract, vitamin D, bone density, children
A gastroenterologist and a rheumatologist answer the questions on the use of non-steroidal anti-inflammatory drugs raised by primary care physicians
Pediatr Med Rodz 2016, 12 (1), p. 28–41
DOI: 10.15557/PiMR.2016.0003

Non-steroidal anti-inflammatory drugs are drugs of choice for chronic pain, which is most common in chronic conditions, rheumatism in particular. According to current recommendations, these medications should be used continuously or intermittently, and their choice should be tailored to each patient. Unfortunately, non-steroidal anti-inflammatory drugs have multiple adverse effects ranging from the most insignificant dyspepsia to severe upper gastrointestinal bleeding. Therefore, gastroscopy and, in the case of confirmed Helicobacter pylori infection, eradication is advisable for planned long-term treatment with these agents. Long-term use of proton pump inhibitors is recommended in rheumatic patients chronically receiving non-selective non-steroidal anti-inflammatory drugs, while celecoxib (a selective COX-2 inhibitor) combined with proton pump inhibitor should be administered in patients at high risk of gastrointestinal complications. In rheumatic patients, the type of non-steroidal anti-inflammatory drug and the route of its administration should be tailored to each patient in terms of strength and duration of drug action, the type of disease and comorbidities as well as contraindications. Adverse gastrointestinal effects are due to the mechanism of action of non-steroidal anti-inflammatory drugs, and therefore independent of the route of administration. The use of proton pump inhibitors with cardioprotective doses of aspirin should be limited to patients with risk factors for gastrointestinal complications. High non-steroidal anti-inflammatory drug doses are limited to gout attack, acute pain and axial spondyloarthropathy showing high clinical activity. In other cases, the lowest effective non-steroidal anti-inflammatory drug dose is recommended. Advancing age is characterised by impairment in the function of all organs, therefore elderly patients should receive lower non-steroidal anti-inflammatory drug doses. Concomitant use of two or more non-steroidal anti-inflammatory drugs in rheumatic diseases is not recommended. According to the latest recommendations, non-steroidal anti-inflammatory drugs can be combined with paracetamol and medicinal products with different mechanisms of action.

Keywords: osteoarthritis, spondyloarthropathies, proton pump inhibitors, non-selective non-steroidal anti-inflammatory drugs, complications
Immunostimulation with oral vaccines for prevention and treatment of respiratory tract infections
Pediatr Med Rodz 2016, 12 (1), p. 42–53
DOI: 10.15557/PiMR.2016.0004

The respiratory system is susceptible to unfavourable effects of biological and non-biological factors. In the protection against infectious agents, the immune system plays a crucial role thanks to close cooperation of specific (acquired) and non-specific (natural, innate) immune mechanisms. A non-specific response actively supports specific response mechanisms. This enables effective protection of our body against infections, both at the stage when pathogens reach the organism and after their penetration into tissues. A stimulation with microbial antigens leads to the activation of specific immunity mechanisms: humoral and cell-mediated responses. In the humoral response, specific immunoglobulins of various classes are involved to protect from recurrent infections. The knowledge of immunity development enables immune system stimulation with pharmaceutical products. The most common immunostimulants are non-specific and specific bacterial vaccines. The main goal of vaccines is the protection of healthy individuals against infections. Conventional prophylactic vaccines are immunogenic products. They contain a combination of extracts of various bacteria, usually ones that are aetiological factors of upper respiratory tract infections. Non-specific vaccines are administered to provoke a specific immune response towards antigens contained in the vaccine. They are bacterial immunostimulants acting mainly by stimulation and mobilisation of host defensive mechanisms. They improve antibacterial serum properties by increasing the level of natural antibodies. If needed, these reactions should be easily stimulated by a pathogen present in nature and should effectively neutralize or limit the disease. In patients who have been treated with a non-specific vaccine, decreased numbers of episodes of respiratory tract infections as well lower antibiotic intake were noted.

Keywords: respiratory tract infections, non-specific vaccines, bacterial lysates, immunostimulants, immunomodulators
Urinary tract infection in children during their first year of life as evidenced by the Department of Paediatrics, Paediatric Nephrology and Allergology, Military Institute of Medicine
Pediatr Med Rodz 2016, 12 (1), p. 54–68
DOI: 10.15557/PiMR.2016.0005

Urinary tract infections are the most common type of infection of bacterial origin in the paediatric population. The main aetiological factor for urinary tract infections are Gram-negative bacteria colonising the gastrointestinal tract, subpreputial area or vaginal vestibule. The most common cause of the infection is Escherichia coli. Quite frequently a urinary tract infection may be the first symptom of anatomical or functional abnormalities in the urinary tract; therefore, special attention should be paid to urinary tract infection incidents in the youngest age group. Cases of children aged 1–12 months during a first-time urinary tract infection episode hospitalised at the Department of Paediatrics, Paediatric Nephrology and Allergology of the Military Institute of Medicine in 2008–2014 were assessed retrospectively. The method of retrospective analysis of medical records was used. A group of 217 children was assessed, with girls slightly outnumbering boys. The most commonly observed symptom was fever, which was often accompanied by symptoms indicating a respiratory tract infection. This fact is worth emphasising since in such cases the presence of a urinary tract infection may be overlooked. Elevated inflammation parameters were observed in the majority of patients. The most common cause of the infection was Escherichia coli. A normal ultrasound image of the urinary tract was reported in only 17% of children. In 60% of patients who had a voiding cystourethrography no abnormalities were observed, in 30% vesicoureteral reflux was found and in 7% of such patients posterior urethral valves were the primary abnormality. Clinical symptoms and inflammation parameter values did not differentiate children with an isolated infection, vesicoureteral reflux and other urinary tract defects. In patients with urinary tract defects other than vesicoureteral reflux a different cause of the infection than Escherichia coli was significantly more common – strains of Gram-positive bacteria were more frequently found.

Keywords: urinary tract infection, infants, abdominal ultrasound scan, vesicoureteral reflux
Serum S100B protein concentration in adolescents with syncope
Pediatr Med Rodz 2016, 12 (1), p. 69–76
DOI: 10.15557/PiMR.2016.0006

Introduction: Children and adolescents with syncope are frequent patients in a general practitioner’s or paediatrician’s office. Syncope is a sudden, reversible, short and spontaneously resolving loss of consciousness associated with transient global cerebral hypoperfusion. The pattern of metabolic and clinical disorders resulting from brain ischaemia has been well described in patients with cerebral stroke. Due to brain ischaemia during stroke, the blood–brain barrier is broken down, which results in the appearance of S100B protein in the cerebrospinal fluid. Its concentration increases with increasing extent of ischaemia. The aim of the study was to assess whether adolescents with syncope present elevated serum S100B protein concentrations. Material and methods: The analysis involved 70 adolescents at 14–18 years of age (average age: 15.5), including 32 syncope patients and 38 controls. The basic diagnostic test was a tilt test performed in accordance with the Westminster protocol. S100B assay was conducted by collecting blood samples directly before a tilt test as well as 6 and 24 hours afterwards. Results: There were no differences between patients and controls in S100B levels at baseline and after 6 and 24 hours. Conclusions: The results of the study do not confirm the hypothesis that during syncope in adolescents, the brain tissue becomes damaged, which would be indicated by elevated serum S100B protein level. This research project requires continuation, and further analyses should be conducted taking into account various types of syncope, particularly the cardioinhibitory one, during which cardiac asystole of 3–15 seconds (or even longer) is observed.

Keywords: syncope, S100B protein, presyncope, adolescent
Spirometry in a long-term follow-up in children with allergic rhinitis
Pediatr Med Rodz 2016, 12 (1), p. 77–84
DOI: 10.15557/PiMR.2016.0007

Allergic rhinitis is currently considered the most common allergic condition. The ECAP (Epidemiology of Allergic Disorders in Poland) study, which was conducted in Poland between 2006 and 2008, found that allergic rhinitis affects 23.6% of children aged 6–7 years, 24.6% of children aged 13–14 years and 21.0% of adults aged 35–44 years. It was shown that allergic rhinitis causes a nine-fold increase in the risk of allergic asthma. The aim of the study was to assess the risk of asthma in children with allergic rhinitis based on spirometric identification of bronchial obstruction. A three-year follow-up was conducted in a group of 60 children, including 37 study patients with diagnosed allergic rhinitis and 23 controls. Three (8.1%) children in the study group developed asthma. Despite normal spirometry findings in the three asthmatic children with allergic rhinitis, comparison analyses indicated statistically significant differences in FEV1 and FVC values between the study group with allergic rhinitis and asthma and the controls. Normal spirometry results in most monitored children, suggesting the absence of lower respiratory inflammation, may be associated with an adequate control of allergic rhinitis as a result of proper treatment.

Keywords: spirometry, allergic rhinitis, asthma, recurrent respiratory infections, children
An assessment of vitamin D serum levels in allergic children
Pediatr Med Rodz 2016, 12 (1), p. 85–93
DOI: 10.15557/PiMR.2016.0008

In recent years, there has been a worldwide increase in the incidence of allergy, particularly in the paediatric population. The most common allergic conditions include asthma, allergic rhinitis, allergic conjunctivitis, atopic dermatitis, food allergies and urticaria. There are a number of publications showing the importance of serum vitamin D levels in atopic diseases. The effects of vitamin D on the balance between Th1 and Th2 lymphocyte-mediated immune response as well as the antiinflammatory effects by limiting TNF-α overproduction are emphasised. The role of vitamin D in the formation of natural endogenous antibiotics and antimicrobials, such as defensins and cathelicidins, is also known. Aim of the study: The aim of the study was to assess serum vitamin D levels in allergic children. Material and methods: Children diagnosed with allergy and/or monitored for atopic disease as well as children with recurrent respiratory infections were included in the study. The children were diagnosed and treated at the Department of Paediatrics, Paediatric Nephrology and Allergology of the Military Institute of Medicine in the period from September 2011 to August 2013. A total of 60 children were qualified to a group with allergy diagnosis (group I), and 49 children formed a group with recurrent respiratory infections (group II). Vitamin D levels were measured in 109 children aged from 2 months to 18 years. Results: Low levels of vitamin D (below the normal limit) were shown in both paediatric groups. No statistically significant (p = 0.25) effects of the season on vitamin D levels were found in the whole evaluated population of children. A statistically significant (p < 0.0001) negative correlation was shown between vitamin D serum levels and the age of the assessed children (vitamin D levels decreased with age).

Keywords: vitamin D, allergy, atopic diseases, children
Transfusion-related acute lung injury (TRALI) – a case report
Pediatr Med Rodz 2016, 12 (1), p. 94–100
DOI: 10.15557/PiMR.2016.0009

Transfusion-related acute lung injury is defined as acute respiratory failure which develops during or within 6 hours after transfusion of a blood component in a patient with no risk factors for respiratory insufficiency. Transfusion-related acute lung injury is diagnosed based on clinical manifestation and by excluding other causes of acute lung injury. Unambiguous diagnosis is difficult. Looking for anti-HLA and/or anti-HNA antibodies in donors and sometimes in recipients plays an important role in lab tests. Negative antibody findings, either in a donor or in a recipient, do not exclude transfusion-related acute lung injury, which, however, does not exempt from performing leukocyte antibody tests since they are extremely important for transfusion-related acute lung injury prophylaxis. The ways to prevent this reaction include: disqualifying donors with anti-HLA/HNA antibodies, screening for antibodies in multiparous women and in individuals after transfusion, modifying the way blood components are prepared and limiting blood transfusion in clinical practice. The paper presents a case of a 38-year-old woman with acute myeloid leukaemia, hospitalised at the Department of Internal Diseases and Haematology of the Military Institute of Medicine for subsequent courses of chemotherapy. During treatment, the patient had red cells and platelets concentrates transfused several times with no transfusion-related reactions. Eight days after the last chemotherapy infusion, the patient developed high temperature and her platelet count was 14 × 103/mL. Therefore, the patient received a platelet concentrate again. About 1 hour after transfusion, the patient complained about chest pain and dyspnoea. She needed oxygen therapy. Chest X-ray revealed lung oedema with no signs of left ventricular failure. Once other causes of acute lung injury were excluded, transfusion-related acute lung injury was diagnosed.

Keywords: transfusion-related acute lung injury (TRALI), HLA/HNA antibodies, diagnostics, TRALI prevention