Does protein intake correlate with tubular function in very preterm neonates?

Background High protein intake in very preterm neonates (VPN) is important for growth. However, preterm kidneys have fewer functional nephrons and many of the ones present may be immature. Studies have shown that high protein intake induces nephron hypertrophy, proteinuria, and glomerular sclerosis, which lead to tubular injury. Urinary neutrophil gelatinase-associated lipocalin (uNGAL) is a biomarker that is released during proximal tubular cell injury. The uNGAL to creatinine (uNGAL/Cr) ratio is commonly performed for normalization. Objective To assess for a possible association between protein intake and uNGAL/Cr ratio in VPN. Methods A prospective cohort study was conducted in two NICUs in Jakarta. Subjects’ urine specimens were collected at 0-48 hours, 72 hours, and 21 days after birth to determine uNGAL/Cr ratio as a biomarker of tubular injury. Protein was administered according to study sites NICU guidelines. Protein intake was recorded daily from 14-21 days of age for formula and measured twice with a human milk analyzer for breast milk. ELISA was used to measure uNGAL concentration. Low protein intake was defined as <3g/kg/day and high protein intake was defined as ?3g/kg/day. Maternal and perinatal variables were recorded from medical records. Results Fifty-nine VPN were recruited, of whom 39 completed the study. Median uNGAL/Cr ratio ranged from 0.32-104.11 ng/mg. The uNGAL/Cr ratio was not correlated with protein intake but was inversely correlated with gestational age and birth weight [r = -0.320, P=0.019 for the 72-hr (T2) urinary collection]. Higher uNGAL/Cr levels were associated with maternal infection [14.4 (range 4.4-104.1) vs 7.2 (range 0.5–32.4) ng/mg, P=0.004 at the 0-48-hr (T1)], maternal anemia [6.9 (range 1.2–66.6) vs 1.7 (range 0.3–89.2) ng/mg, P=0.001 at the 21-day (T3)] and nephrotoxic medication [15.9 (range 1.3–63.8) vs 1.0 (range 0.4–8.6) ng/mg, P=0.026 at the 72-hr]. Conclusion Protein intake according to current nutritional guidelines does not correlate with tubular injury in VPN, as measured by uNGAL/Cr ratio. Maternal infection, maternal anemia, lower birth weight, and nephrotoxic medication, were associated with higher uNGAL/Cr levels in VPN

Sindrom Nefrotik Idiopatik Resisten Steroid pada Anak: Telaah Perbandingan Panduan Klinis

Latar belakang. Sindrom nefrotik idiopatik merupakan penyakit ginjal tersering pada anak di dunia. Penelitian terkait sindrom nefrotik idiopatik pada anak terus berkembang. Namun, pada praktiknya masih terdapat variasi yang lebar terkait evaluasi dan tata laksana sindrom nefrotik idiopatik pada anak di dunia. Tujuan. Membandingkan panduan klinis sindrom nefrotik idiopatik sensitif steroid pada anak. Metode. Membandingkan empat panduan klinis sindrom nefrotik idiopatik sensitif steroid pada anak, yaitu panduan klinis sindrom nefrotik idiopatik Ikatan Dokter Anak Indonesia tahun 2012, Kidney Disease Improving Global Outcome tahun 2021, International Pediatric Nephrology Association tahun 2022, dan Indian Society of Pediatric Nephrology tahun 2021. Dikembangkan 7 lingkup bahasan kajian, meliputi diagnosis, pemeriksaan penunjang awal, batasan kriteria, dan terapi sindrom nefrotik inisial, sindrom nefrotik relaps jarang, sindrom nefrotik relaps sering dan sindrom nefrotik dependen steroid. Hasil. Didapatkan beberapa perbedaan mendasar yang ditemukan, antara lain, terkait batasan proteinuria dan hipoalbuminemia yang digunakan, dosis maksimal steroid, definisi relaps sering, pilihan terapi imunosupresan pada SN relaps sering, dependen steroid, dan pemeriksaan genetik yang dirasonalisasikan berdasarkan bukti-bukti penelitian terbaru. Kesimpulan. Terdapat beberapa perbedaan mendasar antara panduan klinis sindrom nefrotik idiopatik Ikatan Dokter Anak Indonesia tahun 2012 dengan panduan klinis terbaru lainnya. Perlu dipertimbangkan pembaharuan konsensus sindrom nefrotik di Indonesia dengan menelaah bukti ilmiah terbaru dan disesuaikan dengan ketersediaan obat serta fasilitas pemeriksaan di Indonesia

Peran Transforming Growth Factor-B1 pada Penyakit Ginjal

Peran sitokin dan faktor pertumbuhan(growth factor)sangat penting dalam proses inflamasi yang mendasari pembentukan jaringan sklerotik dan fibrosis pada glomerulonefritis. Transforming growth factor(TGF)-E1 merupakan sitokin multipoten yang disekresi oleh berbagai sel dalam tubuh. Sitokin TGF- E1 mempunyai kapasitas untuk mengaktivasi fibroblas interstisial, menginduksi apoptosis (yang menyebabkan sel intrinsik ginjal hilang, digantikan dengan jaringan fibrotik), dan diferensiasi sel tubulus menjadi miofibroblas, sehingga terjadi pembentukan jaringan parut ginjal. Jumlah (TGF)-E1 di daerah tubulo-interstisial berkorelasi dengan derajat inflamasi interstisial dan atrofi tubulus. Keterlibatan TGF-E1 pada pembentukan jaringan parut ginjal juga melalui peningkatan sintesis matriks ekstra selular. Diketahui bahwa TGF-E1 berperan dalam progresivitas penyakit ginjal. Kadar TGF-E1 di dalam urin kasus glomerulonefritis dengan proteinuria berat, sangat meningkat, dan kadarnya sebanding dengan derajat proteinuria. Peran TGF-E1 dalam progresivitas penyakit ginjal juga melalui terjadinya hipertensi. Angiotensin II sebagai hasil aktivasi sistim renin-angiotensin menstimulasi produksi TGF-E1. Inhibitor enzim konvertase (ACEI) dan atau antagonis reseptor angiotensin II terbukti dapat menurunkan proteinuria dan produksi TGF-E1, sehingga kedua obat tersebut dikenal mempunyai efek reno-proteksi

Telaah Kritis Makalah Uji Klinis

Evidence based medicine (EBM) ialah suatu cara pendekatan untuk memanfaatkan bukti mutakhir yang sahih dalam tatalaksana pasien. Untuk dapat memanfaatkan bukti mutakhir diperlukan kemampuan untuk melakukan telaah kritis terhadap makalah atau hasil penelitian orang lain sebelum kita mengadopsi hasil penelitian tersebut. Cara pendekatan EBM mengajarkan pokok-pokok untuk melakukan telaah kritis terhadap sebuah makalah dengan 3 patokan yang disingkat sebagai VIA, yaitu: "Validity" atau kesahihan penelitian, "Important" yang berarti pentingnya hasil penelitian, serta "Applicability" penerapan (aplikasi) hasil penelitian tersebut pada lingkungan kit

Nefritis Tubulointerstisialis pada Kasus Anak yang Menjalani Biopsi Ginjal

Latar belakang. Nefritis tubulointerstisialis (NTI) adalah sindrom yang merupakan spektrum penyakit akut dan kronik, yang secara histologis ditandai oleh inflamasi dan kerusakan struktur tubulus dan interstisial, dengan sedikit pengaruh pada elemen glomerular dan vaskular. Diagnosis pasti ditegakkan berdasarkan biopsi ginjal, karena tidak ada pemeriksaan klinis dan penunjang non invasif yang spesifik dan sensitif. Tujuan. Mengetahui gambaran histopatologi yang menunjukkan keterlibatan tubulointerstisialis serta hubungannya dengan gambaran klinis dan laboratorium pada kasus anak usia kurang dari 18 tahun yang menjalani biopsi ginjal pada periode 2005-2009. Metode. Penelitian retrospektif deskriptif dengan sumber data sekunder rekam medik Departemen Ilmu Kesehatan Anak dan Departemen Patologi Anatomi Fakultas Kedokteran Universitas Indonesia – RS Dr. Cipto Mangunkusumo Jakarta. Hasil. Terdapat 45 kasus anak yang menjalani biopsi ginjal, terdiri dari 24 orang laki-laki dan 21 perempuan yang berusia 6 bulan sampai 16 tahun. Indikasi biopsi adalah glomerulonefritis akut, sindrom nefrotik, nefritis lupus, dan tumor ginjal. Gambaran klinis yang ditemukan yaitu edema, hipertensi, oliguria, demam, pucat, dan muntah. Gambaran laboratorium yaitu peningkatan kreatinin, asidosis metabolik, hipokalemia, proteinuria, hematuria, dan leukosituria steril. Gambaran nefritis tubulointerstisialis adalah infiltrasi sel radang kronik, atrofi tubulus, fibrosis interstisialis, dan edema interstisialis. Beberapa gejala yang lebih banyak terjadi pada pasien dengan lebih atau sama dengan satu kelainan tubulointerstisialis yaitu demam (p<0,05), anemia, muntah, dan asidosis metabolik. Kesimpulan. Nefritis tubulointerstisialis sebagai suatu entitas diagnosis cukup banyak ditemukan dan perlu diberikan lebih banyak perhatian, dalam upaya menurunkan morbiditas dan mortalitas dari penyakit ginjal pada anak

Urinalysis as a diagnostic tool for febrile urinary tract infection in children aged 2 months - 2 years

Background Children aged 2 months to 2 years with febrile urinary tract infection (UTI) need special attention considering kidney complications, unspecified symptoms, and difficult urine sample collection. Urinalysis was the main supportive examination for UTI because of its immediate result and widespread availability. Objective To estimate urine nitrite, leukocyte esterase (LE), leucocyturia, bacteriuria, and their combinations as a diagnostic tool for febrile UTI in children aged 2 months to 2 years. Methods This is a diagnostic study held in Cipto Mangunkusumo Hospital, Tangerang General Hospital, Fatmawati Hospital, and Budhi Asih Hospital, involving 7 5 children aged 2 months to 2 years. Urine samples for urinalysis and urine culture were collected using urine collector in all subjects. Clinical pathologists who performed urine culture, did not know the results of urinalysis. Results By parallel test analyses, we found that the best diagnostic value was the combination of 3 tests (LE, leucocyturia, and bacteriuria). This combination test showed sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+), and negative likelihood ratio (LR-) of 69%, 95%, 85%, 88%, 13.1, and 0.3. Conclusion The combination test of LE, leucocyturia, and bacteriuria shows high specificity, NPV, and LR+ . Therefore, the negative results of these 3 tests in combination can be used to rule out UTI

The use of topical zinc in tuberculin test

with under-diagnosis or over-diagnosis commonly occurring. The tuberculin test as a supporting examination for tuberculosis infection has a false negative value rate of 10-25%. Also, a majority of children with tuberculosis have lower plasma zinc levels than healthy children. Zinc deficiency may impair the immune response, leading to more false negative skin-test results. Objective To evaluate the effectiveness of topical zinc for augmenting the diameter of tuberculin induration in children with tuberculosis. Methods This unblinded, clinical trial was performed from October to December 2012 in subjects matched with themselves. Subjects were children with tuberculosis aged 2-18 years at the Department of Child Health at Cipto Mangunkusumo Hospital and Persahabatan Hospital. Every subject was injected tuberculin in volar region of left and right arm. Test sites then were covered with topical zinc cream on the right arm and placebo cream on the left arm. Indurations were measured after 72 hours. The difference of tuberculin diameter of 3 mm was considered as clinically significant. Data analysis was performed with Wilcoxon signed rank test. Results There were 47 subjects in this study. The majority of subjects were well-nourished (53%). Subjects’ median treatment duration was < 6 months, median age was 72 months and 47% of subjects were under the age of five years. Sixteen subjects had a median 1 mm difference in tuberculin induration diameter between the zinc arm and placebo arm (P<0.001), but this was clinically insignificant. Twenty-two subjects (43%) had Koch reaction after zinc cream application, but the placebo cream did not cause Koch reaction. Conclusion Application of topical zinc does not increase tuberculin induration compared to placebo

Kidney Disease Profiles Among Adolescents In Indonesia

Background: Each kidney injury may develop into chronic kidney disease (CKD) and end stage renal disease (ESRD) that associates with high mortality and socio-economic burden. There is limited data about clinical characteristics of children having CKD in developing countries, espesially in Indonesia. Objective: To describe clinical profiles and characteristics of kidney diseases in adolescents aged 15-18 years. Methods: This study was a cross-sectional study which used data from National Basic Health Survey (Riskesdas) 2013. There were 2 data groups. The first data group included questionnaires about history of kidney stone disease, hypertension, chronic renal failure, antihypertension administration, and blood pressure measurement. The second data group included subsamples of the first group which had laboratory test results, i.e. hemoglobin and serum creatinine levels. All of the data were classified by nutritional status, estimated glomerulofiltration rate (eGFR), blood pressure classification, and hemoglobin level. Results: Among 52,454 adolescents in the first data group, 20,537 (39%) had kidney diseases with female predominance and good nutritional status. Other findings found were history of kidney stone disease (0.2%), chronic renal failure (0.1%), history of hypertension (0.6%), antihypertensive agents consumption (0.1%). Prehypertension and hypertension were found in 51% and 48.3% of adolescents, respectively. Adolescents with decreased eGFR were accounted for 1.4%. Conclusion: The proportion of prehypertension and hypertension in adolescents aged 15-18 years in Indonesia is high. Hence, routine blood pressure measurement is important for early detection and prevention of kidney disease progression. Keywords: adolescent, kidney disease, hypertension, prehypertension, National Basic Health Surve