Is Neck Circumference a Marker for Cardiovascular Risk in Obese Adolescents?

Background: Weight excess has become a public health problem worldwide, reaching about 200 million children, of whom 40 to 50 million are obese. Obesity in childhood is associated with increased blood pressure (BP), high triglycerides, low HDL-cholesterol and abnormal glucose metabolism. Visceral fat is a stronger predictor of metabolic dysfunction and cardiovascular risk than total body adiposity. Assessment of neck circumference (NC) is an easy method, which can serve as screening to identify individuals with weight excess. Our study aim was to examine associations between NC with BP values, lipid profile, blood glucose and fasting insulin in obese adolescents and verify the reproducibility of measurements of NC. Methods: 82 adolescents aged 10 to 17 years were included in the study, being 43 (22 boys and 21 girls) with obesity and 39 with normal weight (20 boys and 19 girls). Results: Significant associations were observed between NC and BMI, BP, HDL cholesterol, insulin and HOMA-IR. Disagreement between both observers for NC was observed in 5.2% of the sample, only concerning obese individuals. Conclusion: Our findings strengthen the knowledge about the potential value of NC as a tool for identifying patients at risk for hypertension, insulin resistance, and obesity. However as with the waist circumference it may be flawed in obese individuals

Abdominal circumference measurement by ultrasound does not enhance estimating the association of visceral fat with cardiovascular risk

Objectives: To evaluate the association between visceral fat and cardiovascular risk factors and to compare the ultrasonographic measurements of abdominal visceral fat with abdominal circumference (AC).Methods: This observational cross-sectional study categorized pubertal and postpubertal adolescents into a control group (n = 49) and an obese group (n = 46). Weight, height, AC, blood pressure, biochemical tests (lipid profile, triacylglycerols, fasting glucose for insulinemia, and serum uric acid), and ultrasound to measure visceral fat were assessed.Results: We found significant differences in the vascular risk variables between the groups, except for total cholesterol and fasting blood glucose level. We also observed that 31 subjects in the control group presented abnormalities in cardiovascular risk factors. the correlations between abdominal visceral fat (measured by ultrasound or the AC) and cardiovascular risk factors were significant. in the entire sample, AC presented better sensitivity and specificity than the ultrasound-measured abdominal visceral fat for identifying the presence of a cluster of at least three cardiovascular risk factors (areas under the receiver operating characteristics curve 0.87 and 0.73, respectively).Conclusion: Ultrasonographic measurements of visceral fat were correlated with cardiovascular risk factors, but this association was also demonstrable with AC measurements. Our results suggest that the measurement of visceral fat by ultrasound is unnecessary for the diagnosis of cardiovascular risk in well-nourished or obese adolescents. (C) 2013 Elsevier Inc. All rights reserved.Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)Universidade Federal de São Paulo, Escola Paulista Med, Dept Pediat, São Paulo, BrazilUniversidade Federal de São Paulo, Escola Paulista Med, Dept Pediat, São Paulo, BrazilFAPESP: 03/02584-8Web of Scienc

Síndrome de Bartter: evaluación del desarrollo estatural y perfil metabólico

OBJECTIVE: Bartter's syndrome is one of the most important inherited diseases that cause chloride leak. The objective of this study was to report the follow-up of ten patients with the syndrome. METHODS: This observational study was based on the review of medical charts reporting the metabolic features, creatinine clearance, nutritional and anthropometric assessment of ten patients with Bartter's syndrome followed at the Nephrology Service of the Universidade Federal de São Paulo (UNIFESP), in their first and last medical appointments, after a mean follow-up period of 43 months (3-76 months). During the follow-up, the management included the administration of potassium (100%) and magnesium (60%) supplements, non-steroidal anti-inflammatory agents (90%), angiotensin-converting enzyme inhibitors (40%) and spironolactone (50%). Statistical analysis was performed comparing the results of first versus last clinical appointment by non-parametric Wilcoxon test. RESULTS: Improvement of serum electrolytes and statural growth after the treatment was observed but only serum potassium [3.05mEq/L versus 3.25 mEq/L (p=0.01)] and weigh-for-age Z-score [initial median -2.47 versus -1.35 (p=0.02)] improved significantly. Out of the ten patients studied, two presented decrease of creatinine clearance with chronic kidney disease at stage 2 at the end of the follow-up. These patients had already started the follow-up with decreased creatinine clearance. CONCLUSIONS: There is a need of early treatment of patients with Bartter's syndrome in order to improve their electrolytes and nutritional condition without compromising the creatinine clearance.OBJETIVO: El síndrome de Bartter (SB) es una enfermedad rara, pero una de las más frecuentes condiciones congénitas perdedoras de cloro. Este trabajo tiene por objetivo relatar la evolución de diez pacientes con SB. MÉTODOS: Estudio observacional, descriptivo, obtenido mediante análisis de prontuarios médicos. Relata el perfil metabólico, la depuración de creatinina, el estado nutricio-nal y ponderoestatural de los diez pacientes atendidos en el ambulatorio de Tubulopatías de Universidade Federal de São Paulo (UNIFESP) con características clínico-laboratoriales de SB, seguidos por un periodo mediano de 43 meses (3-76 meses). Durante el seguimiento se practicó protocolo de tratamiento que consistió en la administración de suplemento de potasio (100%), magnesio (60%), anti-inflamatorios no hormonales (90%), inhibidores de enzima convertidora de angiotensina (40%) y espironolactona (50%). Se consideraron criterios de exclusión la presencia de alteraciones séricas y urinarias no compatibles con SB. El análisis estadístico constó de la comparación de datos de la primera y la última consulta, utilizándose la prueba de Wilcoxon. RESULTADOS: Se observó mejora numérica de los valores absolutos de los ítems evaluados y del desarrollo ponderoestatural con la terapéutica utilizada, pero solamente la calemia [mediana inicial 3,05mEq/L y final 3,25mEq/L (p=0,01)] y el escore Z de peso/edad [mediana inicial -2,47 y final 1,35 (p=0,02)] presentaron mejora significante. De los 10 pacien-tes estudiados, dos presentaban reducción de la depuración de creatinina con enfermedad renal crónica etapa 2 y en el final del seguimiento (ambos habían iniciado el seguimiento con depuración renal comprometida). CONCLUSIONES: Los datos enfatizan la necesidad de la ins-titución terapéutica precoz para mejorar los niveles séricos de los electrólitos y el estado nutricional, sin comprometer la depuración de creatinina.OBJETIVO: A síndrome de Bartter é uma doença rara, porém uma das mais frequentes condições congênitas perdedoras de cloro. Este trabalho teve como objetivo relatar a evolução de dez pacientes com a síndrome. MÉTODOS: Estudo observacional, descritivo, realizado pela análise de prontuários médicos relatando o perfil metabólico, a depuração de creatinina, o estado nutricional e pôndero-estatural de dez pacientes atendidos no Serviço de Nefrologia da Universidade Federal de São Paulo (UNIFESP) com características clínico-laboratoriais da síndrome de Bartter, seguidos por um período médio de 43 meses (3-76 meses). Durante o acompanhamento, o tratamento consistiu na administração de suplemento de potássio (100%), magnésio (60%), anti-inflamatórios não hormonais (90%), inibidores de enzima conversora de angiotensina (40%) e espironolactona (50%). A análise estatística constou da comparação dos dados da primeira e da última consulta, utilizando-se o teste de Wilcoxon. RESULTADOSs: Observou-se melhora dos valores absolutos dos itens avaliados e do desenvolvimento pôndero-estatural com a terapêutica empregada, porém apenas a calemia [mediana inicial 3,05mEqL e final 3,25mEqL (p=0,01)] e o escore Z de peso idade [mediana inicial -2,47 e final -1,35 (p=0,02)] apresentaram melhora significante. Dos dez pacientes estudados, dois apresentavam diminuição da depuração de creatinina com doença renal crônica estágio 2 no final do acompanhamento (ambos tinham iniciado o acompanhamento com depuração renal comprometida). CONCLUSÕES: Há necessidade da instituição terapêutica precoce para melhorar os níveis séricos dos eletrólitos e o estado nutricional dos pacientes acometidos, sem comprometer a depuração de creatinina.Universidade Federal de São Paulo (UNIFESP)UNIFESPSciEL

Cystatin C and renal function in pediatric kidney transplant recipients

In clinical practice, the glomerular filtration rate (GFR) is often determined with serum creatinine. However, studies have shown cystatin C to be a better parameter for the diagnosis of impaired renal function. We compared GFR estimated by plasma cystatin C with GFR estimated by serum creatinine in a sample of 50 pediatric renal transplant recipients and 24 healthy children. The correlation between GFR estimated by serum creatinine and by cystatin C was significant (r = 0.75; P < 0.001, Person’s correlation); however, in pediatric kidney transplant recipients, the GFR was 6.7 mL/min lower when determined using cystatin C rather than serum creatinine. Moreover, using GFR estimated by cystatin C we found that 42% of the pediatric kidney transplant recipients had an estimated GFR <60 mL·min-1·1.73 (m²)-1, whereas when GFR was estimated by the serum creatinine formula only 16% of the children had values below this cutoff point indicative of chronic kidney disease (P < 0.001). We conclude that, in pediatric kidney transplant recipients, estimation of GFR yields lower values when cystatin C is used rather than serum creatinine.Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)Universidade Federal de São Paulo (UNIFESP) Departamento de Medicina Disciplina de NefrologiaUniversidade Federal de São Paulo (UNIFESP) Departamento de PediatriaUNIFESP, Depto. de Medicina Disciplina de NefrologiaUNIFESP, Depto. de PediatriaFAPESP: 04/10342-7SciEL

Serum endocan levels associated with hypertension and loss of renal function in pediatric patients after two years from renal transplant

Endocan is an important biomarker of inflammation and endothelial dysfunction that increases in association with several chronic diseases. Few published data have described the role of endocan in pediatric renal transplant (RT) patients. We evaluated the endocan concentrations in 62 children who underwent renal transplantation and assessed their relationships with the patients' blood pressure and loss of renal function. The endocan levels were significantly elevated in the pediatric RT patients who had hypertension and a loss of renal function. We determined positive correlations between the endocan concentrations and the hemodynamic variables (systolic blood pressure: r = 0.416P = 0.001pulse pressure: r = 0.412P = 0.003). The endocan levels were inversely correlated with the estimated glomerular filtration rate (r = -0.388P = 0.003). An endocan cutoff concentration of 7.0 ng/mL identified pediatric RT patients who had hypertension and a loss of renal function with 100% sensitivity and 75% specificity. In conclusion, the endocan concentrations were significantly elevated in pediatric RT patients who had both hypertension and a loss of renal function. The correlations between the endocan levels and the hemodynamic variables and the markers of renal function strengthen the hypothesis that it is an important marker of cardiorenal risk.FAPESP (Fundacao de Amparo a Pesquisa do Estado de Sao Paulo, Brazil) [2013/03139-0]CNPq (Conselho-Nacional de Desenvolvimento Cientifico e Tecnologico) [443248/2014-1]Nephrology Division, School of Medicine, Federal University of São Paulo, São Paulo, SP, BrazilPediatrics Department, School of Medicine, Federal University of São Paulo, São Paulo, SP, BrazilNephrology Division, School of Medicine, Federal University of São Paulo, São Paulo, SP, BrazilPediatrics Department, School of Medicine, Federal University of São Paulo, São Paulo, SP, BrazilFAPESP: 2013/03139-0CNPq: 443248/2014-1Web of Scienc

Development of a risk score for earlier diagnosis of chronic kidney disease in children

Objective To develop a clinical score for the early identification of chronic kidney disease (CKD) in children and adolescents. The early diagnosis of CKD in childhood allows the adoption of measures to slow the progression of the disease, thereby reducing morbidity and mortality. Nevertheless, the diagnosis is often made too late for proper patient management. Study design We preformed a case-control study of a multicenter Brazilian sample of 752 pediatric patients; the study cases (n = 376) were CKD patients with a median estimated GFR of 37 (IQR = 22 to 57) ml/min/1.73 m(2). The control group (n = 376) comprised age-, gender-and center-matched children who were followed for nonrenal diseases. Potential risk factors were investigated through a standard questionnaire that included symptoms, medical history, and a clinical examination. Two multivariable models (A and B) were fitted to assess predictors of the diagnosis of CKD. Results In model A, 9 variables were associated with CKD diagnosis: antenatal ultrasound with urinary malformation, recurrent urinary tract infection, polyuria, abnormal urine stream, nocturia, growth curve flattening, history of hypertension, foamy urine and edema (c-statistic = 0.938). Model B had the same variables as model A, except for the addition of the history of admission during the neonatal period and the exclusion of antenatal ultrasound variables (c-statistic = 0.927). Conclusions The present scores may serve as a warning sign for CKD diagnosis in children among professionals working in the primary care setting where the symptoms associated with a risk of CKD may be overlooked14

Aspectos da função renal em crianças submetidas à cirurgia cardíaca

BV UNIFESP: Teses e dissertaçõe

Diagnóstico das complicações da função renal em crianças submetidas a cirurgia cardíaca

BV UNIFESP: Teses e dissertaçõe

Signs and symptoms of developmental abnormalities of the genitourinary tract

Objective: The abnormalities of the genitourinary tract development are the leading cause of chronic kidney disease (CKD) in children. The diagnosis of this disease in Brazil is late and incomplete, which results in increased morbidity and mortality in this age group. Early diagnosis of this condition is the prerogative of generalist pediatricians, and the aim of this study was to review the clinical signs and symptoms associated with developmental abnormalities of the genitourinary tract. Data sources: Based on the description of a symbolic clinical case, the authors conducted a non‐systematic review of medical literature. Data synthesis: The results suggest that the following data should be used as a warning for early diagnosis of affected children: a) combined urinary tract abnormalities (chromosomal abnormalities; sequence of malformations [VACTERLand Prune‐Belly]; and musculoskeletal, digestive tract, heart, and nervous system malformations); b) previous history (congenital anomalies of the kidney and urinary tract [CAKUT] in the family, low birth weight, and oligoamnios); c) clinical signs (polyuria/nocturia, urinary tract infection, systemic arterial hypertension, failure to thrive, weak urinary stream, difficulty to start urination, distended bladder, non‐monosymptomatic enuresis, urinary/urge incontinence, and bowel and bladder dysfunction); and d) pre‐ and postnatal ultrasonographic alterations (increased anteroposterior diameter of the renal pelvis, mainly in the third trimester of pregnancy; single kidney; hydronephrosis associated with other abnormalities; and hydronephrosis with parenchymal involvement in the post‐neonatal assessment). Conclusion: The suggestions shown here can help the pediatrician to establish clinical hypotheses for the early diagnosis of developmental abnormalities of the genitourinary tract without resorting to expensive and invasive procedures

What are the factors that influence the attainment of satisfactory energy intake in pediatric intensive care unit patients receiving enteral or parenteral nutrition?

Objective: Children admitted to the intensive care unit (ICU) are at risk of inadequate energy intake. Although studies have identified factors contributing to an inadequate energy supply in critically ill children, they did not take into consideration the length of time during which patients received their estimated energy requirements after having achieved a satisfactory energy intake. This study aimed to identify factors associated with the non-attainment of estimated energy requirements and consider the time this energy intake is maintained.Methods: This was a prospective study involving 207 children hospitalized in the ICU who were receiving enteral and/or parenteral nutrition. the outcome variable studied was whether 90% of the estimated basal metabolic rate was maintained for at least half of the ICU stay (satisfactory energy intake). the exposure variables for outcome were gender, age, diagnosis, use of vasopressors, malnutrition, route of nutritional support, and Pediatric Index of Mortality and Pediatric Logistic Organ Dysfunction scores.Results: Satisfactory energy intake was attained by 20.8% of the patients, within a mean time of 5.07 +/- 2.48 d. in a multivariable analysis, a diagnosis of heart disease (odds ratio 3.62, 95% confidence interval 1.03-12.68, P = 0.045) increased the risk of insufficient energy intake, whereas malnutrition (odds ratio 0.43, 95% confidence interval 0.20-0.92, P = 0.030) and the use of parenteral nutrition (odds ratio 0.34, 95% confidence interval 0.15-0.77, P = 0.001) were protective factors against this outcome.Conclusion: A satisfactory energy intake was reached by a small proportion of patients during their ICU stay. Heart disease was an independent risk factor for the non-attainment of satisfactory energy intake, whereas malnutrition and the use of parenteral nutrition were protective factors against this outcome. (C) 2013 Elsevier Inc. All rights reserved.Universidade Federal de São Paulo, Dept Pediat, Discipline Nutr & Metab, São Paulo, BrazilUniversidade Federal de São Paulo, Dept Pediat, Pediat Nephrol Sect, São Paulo, BrazilUniversidade Federal de São Paulo, Dept Pediat, Discipline Nutr & Metab, São Paulo, BrazilUniversidade Federal de São Paulo, Dept Pediat, Pediat Nephrol Sect, São Paulo, BrazilWeb of Scienc