Hypertensive crisis as the first manifestation of renaldisease in children and adolescents: a report of three cases and review of the literature

Introduction: Hypertensive crisis is a life-threatening condition, defined as severe hypertension complicated with acute target-organ dysfunction (mainly neurological, renal or cardiac). It rarely occurs in childhood and most children and adolescents who presents with hypertensive crisis symptoms have secondary hypertension, mainly of renal etiology. Case reports:We present the cases of three children with severe hypertension of different renal etiology who presented with the characteristic features of hypertensive emergency. Case 1 is a 11-year-old girl with reflux nephropathy who at admission had blood pressure (BP) as high as 250/200 mmHg. She was lethargic, with headache, vomiting and a 3-month history of weight loss. Case 2 is a 13-year-old boy with renal artery stenosis who had clinical presentation of generalized tonic-clonic seizures and BP 220/150 mmHg. Case 3 is a 9-year-old boy with chronic renal insufficiency of unexplained etiology and BP as high as 220/135 mmHg. This patient, like two others, presented dominantly with symptoms of hypertensive encephalopathy, aswell as signs of renal damage. All three patients have documented hypertrophic cardiomyopathy. In the patient who had renal artery stenosis, the removal of his dysplastic atrophic right kidney failed to normalize his blood pressure. Conclusion: We discuss the cases of unrecognized long-standing hypertension, with progression to malignant hypertension, as the first manifestation of renal disease – two with renal parenchymal disorders and one with renovascular disease. Hypertension is underdiagnosed in children and the purpose of these case reports is to raise awareness about it and point to the importance of routine careful measurement of blood pressure in pediatric patients

Hypertensive crisis as the first manifestation of renaldisease in children and adolescents: a report of three cases and review of the literature

Introduction: Hypertensive crisis is a life-threatening condition, defined as severe hypertension complicated with acute target-organ dysfunction (mainly neurological, renal or cardiac). It rarely occurs in childhood and most children and adolescents who presents with hypertensive crisis symptoms have secondary hypertension, mainly of renal etiology. Case reports:We present the cases of three children with severe hypertension of different renal etiology who presented with the characteristic features of hypertensive emergency. Case 1 is a 11-year-old girl with reflux nephropathy who at admission had blood pressure (BP) as high as 250/200 mmHg. She was lethargic, with headache, vomiting and a 3-month history of weight loss. Case 2 is a 13-year-old boy with renal artery stenosis who had clinical presentation of generalized tonic-clonic seizures and BP 220/150 mmHg. Case 3 is a 9-year-old boy with chronic renal insufficiency of unexplained etiology and BP as high as 220/135 mmHg. This patient, like two others, presented dominantly with symptoms of hypertensive encephalopathy, aswell as signs of renal damage. All three patients have documented hypertrophic cardiomyopathy. In the patient who had renal artery stenosis, the removal of his dysplastic atrophic right kidney failed to normalize his blood pressure. Conclusion: We discuss the cases of unrecognized long-standing hypertension, with progression to malignant hypertension, as the first manifestation of renal disease – two with renal parenchymal disorders and one with renovascular disease. Hypertension is underdiagnosed in children and the purpose of these case reports is to raise awareness about it and point to the importance of routine careful measurement of blood pressure in pediatric patients

Kontrastni ultrazvuk u dijagnostici intrarenalnog refluksa u djece

Vezikoureteralni refluks (VUR) ubraja se u najčešće anomalije mokraćnog sustava u djece i može biti povezan s refluksnom nefropatijom (RN). Brojne studije ukazuju da je intrarenalni refluks (IRR) važan rizični faktor za febrilne uroinfekcije i ožiljčenje bubrežnog parenhima te posljedično, kasnije, razvoj hipertenzije i/ili bubrežne insuficijencije. Incidencija intrarenalnog refluksa kod mikcijske cistouretrografije (MCUG) kreće se u rasponu ispod 1% do maksimalno 10%. Pojava kontrastnih mikromjehurića izvan kontura kanalnog sustava odnosno bubrežne čašice te ulazak kontrasta u parenhim bubrega dijagnostički je kriterij intrarenalnog refluksa pri kontrastno pojačanoj ultrazvučnoj cistografiji (ceVUS, engl. contrast-enchanced voiding urosonography). Brojne studije ukazale su na veću dijagnostičku pouzdanost ceVUS-a u komparaciji s MCUG kod dokazivanja VUR-a. Od 2006. godine u našoj ustanovi za dijagnostiku VUR-a primjenjujemo ultrazvučne metode, a ceVUS je 2018. godine prihvaćen i uvršten u Algoritam obrade djece s uroinfekcijama od strane Hrvatskoga pedijatrijskog nefrološkog društva. U početku smo IRR otkrivali u svega 2,3% djece s VUR-om, a od 2013. godine, otkada primjenjujemo kontrastom pojačanu ultrazvučnu cistografiju, IRR se otkriva u 11,9% djece s VUR-om. Do sada nema studija koje istražuju učestalost intrarenalnog refluksa ovom metodom. Cilj je ovog rada prikazati mogućnost dijagnostike IRR-a pomoću kontrastnog ultrazvuka, opisati tehniku izvođenja i naše dugogodišnje iskustvo

Akutna otrovanja u bolesnika liječenih u Kliničkoj bolnici "Merkur" u Zagrebu tijekom deset mjeseci 1999. godine

This paper describes 170 cases of acute poisoning in 60 men and 110 women admitted to emergency room from January through November 1999. Ninety-eight percent of acute poisonings were selfinflicted, and 90% occurred at home. Drugs were used in 134 (79%) suicide attempts. Eighty-one acute poisonings were caused by benzodiazepines (48%) and 19 by antidepressants (11%). Alcohol intoxication, alone or combined with the intake of psychoactive drug (28 cases, 16%) predominated in men. Cocaine was the most common narcotic drug, taken by 31 patients (16%). Other acute poisonings involved ecstasy (4 cases), CO (6 cases), and HCl inhalation (2 cases). Previous suicide attempts due to depression were found in 68 patients (40%). Fifty patients (29%) were comatose on admission, 24 were transferred to intensive care, and 3 died. Data such as these can be very useful for handling self-inflicted acute poisonings and for planning long-term health care activities.Analizirano je 170 slučajeva akutnih otrovanja u 60 pacijenata i 110 pacijentica (srednja dob 31 godina) koji su obrađivani u Hitnoj internoj poliklinici Kliničke bolnice "Merkur" u razdoblju od 1. siječnja do 1. studenoga 1999. U 168 (98%) pacijenata otrovanje je bilo namjerno izazvano. Devedeset posto otrovanja dogodilo se kod kuće. U 134 (79%) pacijenata samoubojstvo je pokušano lijekovima. Uzrok akutnog otrovanja u 81 (48%) bili su benzodiazepini, a u 19 (11%) slučajeva antidepresivi. Pretežiti uzrok otrovanja u muškaraca bio je alkohol (u 18 slučajeva, 11%) ili kombinacija alkohola i psihoaktivnog preparata (u 10 slučajeva, 6%). Narkotici su bili uzročnici akutnog otrovanja u 31 (18%) pacijenata i među njima bio je najzastupljeniji kokain. Ostali uzročnici akutnog otrovanja bile su sintetske droge kao ecstasy (3 slučaja, 2%) te udisanje ugljičnog monoksida (6 slučaja, 4%) i klorovodične kiseline (2 slučaja, 1%). U 68 (40%) pacijenata pokušaj suicida bio je posljedica depresije. Prethodnih suicidalnih namjera bilo je u 24 (14%) pacijenata. Na prijemu u Hitnu internu polikliniku bilo je ukupno 50 (29%) komatoznih pacijenata, a uzrok otrovanja kokain u 31 (18%), benzodiazepin u 11 (6%) i alkohol u 8 (5%) slučajeva. Od tih pacijenata na daljnjem tretmanu u Jedinici intenzivne njege zadržana su 24 pacijenta. Smrtni ishod zabilježen je u troje pacijenata visoke dobi (više od 70 godina) koji su se otrovali antidepresivima, a uzrok smrti bile su ventrikularna aritmija i respiratorna depresija. Rezultati ovog istraživanja daju korisne podatke kako za pružanje neposredne medicinske skrbi tako i pri planiranju zdravstvene zaštite u namjerno izazvanim akutnim otrovanjima

Ultrasound contrast cystography with contrast enhanced software in the diagnosis of vesicoureteral reflux

Razvojem tehnologije specifičnog softvera osjetljivog na kontrast i uvođenjem ultrazvučnog kontrastnog sredstva mikcijska ultrazvučna cistografija postala je rutinska metoda u dijagnostici vezikoureteralnog refluksa u dječjoj dobi. Mnoge studije pokazuju da je osjetljivost ove metode veća u usporedbi s mikcijskom cistouretrografijom, a vrlo bitna prednost je izostanak korištenja ionizirajućeg zračenja. Posljednjih je godina sve viša svijest o potencijalnim štetnim učincima izloženosti ionizirajućem zračenju kod nekih dijagnostičkih slikovnih postupaka u dječjoj dobi. U članku prikazujemo način izvođenja i karakteristike mikcijske ultrazvučne cistografije uz upotrebu softvera osjetljivog na kontrast te analiziramo prednosti i nedostatke u odnosu na druge dijagnostičke metode koje se koriste u dijagnostici vezikoureteralnog refluksa.Ultrasound contrast cystography has become a routine method in the diagnosis of vesicoureteral reflux in children due to the development of contrast-specific software technology and the introduction of second generation ultrasound contrast. Many studies have shown that this method is more sensitive than voiding cystourethrography but the most important advantage is the lack of use of ionizing radiation. In recent years there is higher awareness of the potential harmful effects of exposure to ionizing radiation in certain diagnostic imaging procedures in children. This article explains characteristics of ultrasound contrast cystography and analyzes the advantages and disadvantages compared to other diagnostic methods used in the diagnosis of vesicoureteral reflux

Current approach to nocturnal enuresis in children

Primarna noćna enureza je čest poremećaj u dječjoj dobi. Etiologija joj je multifaktorska, uz jaku genetičku predispoziciju, u uzrocima dominiraju noćna poliurija, manji funkcionalni kapacitet mokraćnog mjehura i djetetov čvrst san. Novija istraživanja pokazuju da psihičke promjene nisu uzrok, već posljedica noćne enureze. Uzevši u obzir fi ziološko sazrijevanje i uzroke, danas se preporuča aktivno liječenje noćnog mokrenja nakon navršene pete godine života. U članku su iznesene dosadašnje spoznaje o etiologiji primarne noćne enureze u djece, kao i o dijagnostici i suvremenim terapijskim metodama.Primary nocturnal enuresis is a common disorder in childhood. The etiology is multifactorial with a strong genetic predisposition. Most common causes are nocturnal polyuria, decreased functional capacity of the bladder and disorder of arousal from sleep. Recent studies show that psychological changes are not the cause, but the consequence of nocturnal enuresis. Given the physiological maturation and causes, today is advised active treatment of nocturnal enuresis after the age of fi ve. This paper summarizes the current knowledge about the etiology of primary nocturnal enuresis in children, as well as diagnostics and current therapeutic approaches

Videourodynamics combined with contrast-enhanced voiding urosonography – a new method in pediatric nephro-urology

Cilj ovog rada je prikazati videourodinamiku kombiniranu s kontrastnom mikcijskom urosonografi jom koja se primjenjuje u našoj ustanovi otprije 4 godine. Metoda se ne služi ionizirajućim zračenjem i visoko je senzitivna za prikaz vezikoureteralnog refl uksa. Tijekom pretrage simultano se procjenjuje funkcija donjeg mokraćnog sustava, prisutnost i stupanj refl uksa te intravezikalni tlakovi i volumeni kod kojih se refl uks javlja, što je važno u planiranju liječenja kao i u davanju prognoze. U radu analiziramo prednosti i nedostatke ove metode u odnosu na onu standardnu rengensku i opisujemo tehniku izvođenja.The aim of this paper is to show videourodynamics combined with contrast-enhanced voiding urosonography, which has been used at our institution for four years now. This method does not use ionizing radiation and is highly sensitive for vesicoureteral refl ux. During examination, we can simultaneously monitor function of the lower urinary tract, the presence and degree of refl ux, intravesical pressure and the volume at which refl ux occurs, all of these being important for planning of treatment and providing prognosis. We analyze the advantages and disadvantages of this method compared to standard x-ray, and describe the technique of examination

Effects of prestorage heat treatments on Satsuma mandarin fruits (Citrus unshiu Marc., cv. Owari) quality after storage

Istraživan je utjecaj toplinskih predtretmana potapanjem plodova u toplu vodu na 48°C (HWD 48) i 52°C (HWD 52) te kontrole (izostanak predtretmana) na kakvoću plodova mandarine (Citrus unshiu Marc., cv. Owari) nakon 8 tjedana skladištenja na temperaturi od 1 oC. Dobiveni rezultati upućuju da je kod plodova tretiranih toplom vodom došlo do manjeg gubitka na težini u odnosu na kontrolu, a utvrđen je signifikantan utjecaj predtretmana na kakvoću plodova. Boljim predtretmanom se pokazao HWD 48 čijom su se primjenom postigli najmaji gubitci plodova na težini, a zadržala zadovoljavajuća kakvoća.Influence of hot water dipping pre-treatments at 48°C (HWD 48) and 52°C (HWD 52) on Satsuma mandarin fruits (Citrus unshiu Marc., cv. Owari) quality was studied. Measurements of fruit weight loss and basic chemical parameters of fruit quality were carried out after 8 weeks of storage at 1°C temperature. Obtained results indicate that fruits treated by hot water dips underwent a smaller weight loss than those not treated – the control fruits. Besides, a significant impact of applied pre-treatments on fruit quality was found. It was demonstrated that better pre-treatment was HWD 48 by whose utilization mandarin fruits underwent the smallest weight loss and at the same time maintained satisfactory quality

Contemporary approach to neurogenic urinary bladder in children

Neurogeni mokraćni mjehur (NMM) uzrokovan je oštećenjem inervacije donjeg mokraćnog sustava i predstavlja rizik za ponavljane upale mokraćnog sustava, nastanak vezikoureteralnog refluksa, hidronefroze, urolitijaze i oštećenje bubrežne funkcije. Urodinamska ispitivanja omogućila su nam bolje razumijevanje patofiziologije ovih poremećaja i rano otkrivanje čimbenika rizika za oštećenje bubrežnog parenhima. Odmah nakon postavljanja sumnje na neurogeni poremećaj nužna je kompletna nefrološka obrada koja uključuje ultrazvučne metode, 4 satnu opservaciju mokrenja, kontrastnu mikcijsku urosonografiju, urodinamiku i videourodinamiku. Glavni ciljevi liječenja i praćenja su očuvanje bubrežne funkcije, a nakon školske dobi i socijalno prihvatljiva kontinencija. U ovom radu iznosimo suvremeni pristup djetetu s neurogenim mokraćnim mjehurom uz osvrt na vlastito dugogodišnje iskustvo u dijagnostici i liječenju djece i adolescenata s raznim oblicima ovog poremećaja.Neurogenic urinary bladder is caused by impaired innervation of the lower urinary tract and is a risk factor for recurrent urinary tract infections, vesicoureteral reflux, hydronephrosis, urolithiasis and impaired renal function. Urodynamic studies have allowed us to better understand the pathophysiology of these disorders and early detection of risk factors for renal parenchymal damage. Immediately after the suspicion on a neurogenic dysfunction, complete diagnostic workup is necessary, which includes ultrasound methods, 4-hour voiding observation, contrast-enchanced voiding urosonography, urodynamics and videourodynamics. The main goals of treatment and follow-up are the preservation of renal function, and after school age, socially acceptable continence. In this paper, we present contemporary approach to a child with neurogenic bladder with reference to our own many years of experience in the diagnosis and treatment of children and adolescents with various forms of this disorder