Letters to Editor
5.
2000;38:461‑7. McCorkell SJ. Unintended percutaneous aspiration of pulmonary echinococcal cysts. AJR Am J Roentgenol 1984;143:123‑6. Access this article online Quick Response Code:
Website: www.indianjnephrol.org DOI: 10.4103/0971-4065.120348
35 30 25 20 15 10 5 0
Misc. Co-arc Tx
norma l Misc. 2 Co-arc 1 Tx 1 Scar 5 single kidney 5 CKD 10 incidental 7
WCH
MH
1 1 0 3 3 2 9
0 0 1 0 0 2 0
PRE HT 0 0 0 0 0 0 7
AMB HT 0 0 0 0 0 0 5
SEVER E 0 0 0 0 1 0 3
Scar single kidney CKD
incidental
Figure 1: Outcomes of the ambulatory blood pressure monitoring. ABPM = ambulatory blood pressure monitoring, CKD = Chronic Kidney Disease, Co – arc = co-arctation, HT = hypertension, MH= masked hypertension, Misc = miscellaneous, Tx = Renal transplant
Prospective analysis of utility and feasibility of ambulatory blood pressure monitoring service in a pediatric nephrology set up Sir, Despite ambulatory blood pressure monitoring (ABPM) becoming standard of care in adult practice[1] as well as its strong recommendation in pediatric hypertension (HT) guidelines[2,3] there are very few reports on its utility and feasibility in children from emerging economy and none from Indian subcontinent.[4] We hereby present a prospective analysis of an ABPM service initiated in February 2012. Pediatric ABPM service was initiated with Welch Allyn 6100 monitor using appropriate blood pressure (BP) cuff sizes. It was offered to all children above 5 years of age with incidental (without any obvious underlying reason for HT) clinic blood pressure (CBP) persistently ≥95th percentile (p) but ≤99th p +5 mm Hg or as a standard of care for children with chronic kidney disease (CKD) (≥stage 3), post renal transplant (RTx), solitary kidney, renal scar, and post‑op for coarctation of the aorta. The American Heart Association (AHA) recommendation[2] was taken as standard and ABPM limits were set accordingly. Height was used for estimating the ABPM limits or age if height was less than 120 cm.[2,3] Interpretation was as per AHA suggestions‑normal: (CBP < 95th p, mean ABPM < 95th p and systolic load (SL) 95th p, mean ABPM < 95th p and SL < 25%), masked hypertension (MH): (CBP < 95th p, mean ABPM > 95th and SL < 25%), pre‑HT: (CBP > 95th p, mean ABPM < 95th p and SL > 25% but < 50%), ambulatory hypertension (AH): (CBP > 95th p, mean ABPM > 95th p and SL > 25%, Indian Journal of Nephrology
but < 50%) and severe AH: (CBP < 95th p, mean ABPM < 95th p and SL > 50%). Until 31st March 2013; 69 children had ABPM (26% female) with the median age of 9.2 years (range 5‑18). As per the AHA recommendation all of them had at least one reading per hour and the total number of readings were greater than 40 (median number of total reading was 52 with range 41‑72). Sleep diary was used to ascertain day and night time. Underlying reason for undertaking ABPM and the outcome are shown in Figure 1. Incidental HT was the most common underlying reason. WCH was found in 27% (n = 19) of the total subjects and MH in 4% (n = 3). On analysis of utility; ABPM resulted in definite change in management in 36% of the cases (n = 25). Whereas WCH was detected in 19 children MH was detected in three cases (all three cases were of CKD including one post RTx). In addition, anti‑hypertensive medications were increased in another three cases of known hypertensive wherein ABPM showed severe ambulatory HT although CBP was only around 95th percentile. In conclusion, similar to western literature[2] we also found a high incidence of WCH (27%) as well as MH (21% among CKD and RTx). Diagnosis of WCH does avoid further costly investigation as well as use of anti‑hypertensive medications,[5] whereas diagnosis of MH can result in more effective control of BP, which is likely to result in improved renal outcome. Although small in numbers, our study supports the use of pediatric ABPM even in Indian circumstances and should encourage its increased utilization. R. Sinha Departments of Paediatric Nephrology, AMRI Group of Hospitals and Paediatric Medicine, Institute of Child Health, Kolkata, West Bengal, India Address for correspondence: Dr. Rajiv Sinha, 37, G Bondel Road, Kolkata ‑ 700 019, West Bengal, India. E‑mail: [email protected] November 2013 / Vol 23 / Issue 6
463
Letters to Editor
References 1. http://www.guidance.nice.org.uk/CG127/QuickRefGuide/pdf/ English. [Last accessed on 2013 Apr 15]. 2. Urbina E, Alpert B, Flynn J, Hayman L, Harshfield GA, Jacobson M, et al. Ambulatory blood pressure monitoring in children and adolescents: Recommendations for standard assessment: A scientific statement from the American Heart Association Atherosclerosis, Hypertension, and Obesity in Youth Committee of the council on cardiovascular disease in the young and the council for high blood pressure research. Hypertension 2008;52:433‑51. 3. Lurbe E, Cifkova R, Cruickshank JK, Dillon MJ, Ferreira I, Invitti C, et al. Management of high blood pressure in children and adolescents: Recommendations of the European Society of Hypertension. J Hypertens 2009;27:1719‑42. 4. Furusawa ÉA, Filho UD, Junior DM, Koch VH. Home and ambulatory blood pressure to identify white coat and masked hypertension in the pediatric patient. Am J Hypertens 2011;24:893‑7. 5. Swartz SJ, Srivaths PR, Croix B, Feig DI. Cost‑effectiveness of ambulatory blood pressure monitoring in the initial evaluation of hypertension in children. Pediatrics 2008;122:1177‑81.
We compared the clinical and laboratory features of patients of peritonitis due to NTM and those of PD patients with bacterial peritonitis reported during these two years. We could not compare with peritonitis due to M. tuberculosis, for there were only three such patients during this period. The data are reported in Table 1.
Access this article online Quick Response Code:
disease (ESRD) patients were initiated on peritoneal dialysis (PD) at our institute. During this 14‑year period, there were 276 bacterial, 16 tuberculous, 68 fungal, nine nontuberculous mycobacterium (NTM), and 141 culture‑negative peritonitis episodes. The cumulative follow‑up of 650 patients was 13,710 months. We diagnosed nine cases as peritonitis due to NTM. Hence, the incidence of bacterial, tuberculous, NTM, and fungal peritonitis was one episode per 49.6, 856.8, 1523.3, and 201.6 patient–months, respectively. The patients of peritonitis presented in two clusters–in 2005 and 2012. The mean age was 51.11 years. There were eight males. All patients had growth identified as Runyon class IV: Rapid growers. There was growth on Löwenstein–Jensen medium between 4 and 11 days. The organisms were differentiated from Mycobacterium tuberculosis by BACTEC NAP test.[1]
Website: www.indianjnephrol.org DOI: 10.4103/0971-4065.120349
Only fever was found to be significantly associated with peritonitis due to NTM peritonitis when compared to bacterial peritonitis. An index of suspicion for NTM peritonitis would be an episode of peritonitis appearing early after placement of the catheter. Only one previous study [2] identified fever to be present in a higher percentage of patients of NTM peritonitis than in other peritonitis.
Peritonitis due to nontuberculous mycobacterium Sir, Between 1998 and June 2012, 650 end‑stage renal
During the same months of NTM peritonitis, there were reports of infection due to NTM in other surgeries performed at our institute. Culture of tap water and scrapings from the walls of operating room did not yield any growth. However, rapidly growing mycobacteria can be recovered from soil and natural water supplies, and are the most common NTM associated with nosocomial
Table 1: Patients of NTM peritonitis Patient
Age/sex
Cause of end stage renal disease
1 2 3 4 5 6 7 8 9
45/male 46/ male 46/male 65/female 45/male 60/male 48/male 55/male 50/male
CGN HTN CGN DM CGN CGN Renal calculus disease Obstructive nephropathy HTN
Duration of CAPD (days) 40 15 45 26 41 43 20 19 20
Differential cell count of peritoneal fluid
Fever
Neutrophilia Neutrophilia Lymphocytosis Neutrophilia Neutrophilia Neutrophilia Lymphocytosis Lymphocytosis Neutrophilia
Present Present Absent Present Absent Present Present Present Present
Total leucocyte count (×109/L)
Growth on LJ medium (day)
17.0 14.5 19.0 22.0 7.8 25.0 8.0 8.0 5.0
Day 4 Day 11 Day 7 Day 7 Day 7 Day 5 Day 4 Day 6 Day 11
NTM: Nontuberculous mycobacterium, CGN: chronic glomerulonephritis, HTN: hypertension
464
November 2013 / Vol 23 / Issue 6
Indian Journal of Nephrology
Copyright of Indian Journal of Nephrology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
5.
2000;38:461‑7. McCorkell SJ. Unintended percutaneous aspiration of pulmonary echinococcal cysts. AJR Am J Roentgenol 1984;143:123‑6. Access this article online Quick Response Code:
Website: www.indianjnephrol.org DOI: 10.4103/0971-4065.120348
35 30 25 20 15 10 5 0
Misc. Co-arc Tx
norma l Misc. 2 Co-arc 1 Tx 1 Scar 5 single kidney 5 CKD 10 incidental 7
WCH
MH
1 1 0 3 3 2 9
0 0 1 0 0 2 0
PRE HT 0 0 0 0 0 0 7
AMB HT 0 0 0 0 0 0 5
SEVER E 0 0 0 0 1 0 3
Scar single kidney CKD
incidental
Figure 1: Outcomes of the ambulatory blood pressure monitoring. ABPM = ambulatory blood pressure monitoring, CKD = Chronic Kidney Disease, Co – arc = co-arctation, HT = hypertension, MH= masked hypertension, Misc = miscellaneous, Tx = Renal transplant
Prospective analysis of utility and feasibility of ambulatory blood pressure monitoring service in a pediatric nephrology set up Sir, Despite ambulatory blood pressure monitoring (ABPM) becoming standard of care in adult practice[1] as well as its strong recommendation in pediatric hypertension (HT) guidelines[2,3] there are very few reports on its utility and feasibility in children from emerging economy and none from Indian subcontinent.[4] We hereby present a prospective analysis of an ABPM service initiated in February 2012. Pediatric ABPM service was initiated with Welch Allyn 6100 monitor using appropriate blood pressure (BP) cuff sizes. It was offered to all children above 5 years of age with incidental (without any obvious underlying reason for HT) clinic blood pressure (CBP) persistently ≥95th percentile (p) but ≤99th p +5 mm Hg or as a standard of care for children with chronic kidney disease (CKD) (≥stage 3), post renal transplant (RTx), solitary kidney, renal scar, and post‑op for coarctation of the aorta. The American Heart Association (AHA) recommendation[2] was taken as standard and ABPM limits were set accordingly. Height was used for estimating the ABPM limits or age if height was less than 120 cm.[2,3] Interpretation was as per AHA suggestions‑normal: (CBP < 95th p, mean ABPM < 95th p and systolic load (SL) 95th p, mean ABPM < 95th p and SL < 25%), masked hypertension (MH): (CBP < 95th p, mean ABPM > 95th and SL < 25%), pre‑HT: (CBP > 95th p, mean ABPM < 95th p and SL > 25% but < 50%), ambulatory hypertension (AH): (CBP > 95th p, mean ABPM > 95th p and SL > 25%, Indian Journal of Nephrology
but < 50%) and severe AH: (CBP < 95th p, mean ABPM < 95th p and SL > 50%). Until 31st March 2013; 69 children had ABPM (26% female) with the median age of 9.2 years (range 5‑18). As per the AHA recommendation all of them had at least one reading per hour and the total number of readings were greater than 40 (median number of total reading was 52 with range 41‑72). Sleep diary was used to ascertain day and night time. Underlying reason for undertaking ABPM and the outcome are shown in Figure 1. Incidental HT was the most common underlying reason. WCH was found in 27% (n = 19) of the total subjects and MH in 4% (n = 3). On analysis of utility; ABPM resulted in definite change in management in 36% of the cases (n = 25). Whereas WCH was detected in 19 children MH was detected in three cases (all three cases were of CKD including one post RTx). In addition, anti‑hypertensive medications were increased in another three cases of known hypertensive wherein ABPM showed severe ambulatory HT although CBP was only around 95th percentile. In conclusion, similar to western literature[2] we also found a high incidence of WCH (27%) as well as MH (21% among CKD and RTx). Diagnosis of WCH does avoid further costly investigation as well as use of anti‑hypertensive medications,[5] whereas diagnosis of MH can result in more effective control of BP, which is likely to result in improved renal outcome. Although small in numbers, our study supports the use of pediatric ABPM even in Indian circumstances and should encourage its increased utilization. R. Sinha Departments of Paediatric Nephrology, AMRI Group of Hospitals and Paediatric Medicine, Institute of Child Health, Kolkata, West Bengal, India Address for correspondence: Dr. Rajiv Sinha, 37, G Bondel Road, Kolkata ‑ 700 019, West Bengal, India. E‑mail: [email protected] November 2013 / Vol 23 / Issue 6
463
Letters to Editor
References 1. http://www.guidance.nice.org.uk/CG127/QuickRefGuide/pdf/ English. [Last accessed on 2013 Apr 15]. 2. Urbina E, Alpert B, Flynn J, Hayman L, Harshfield GA, Jacobson M, et al. Ambulatory blood pressure monitoring in children and adolescents: Recommendations for standard assessment: A scientific statement from the American Heart Association Atherosclerosis, Hypertension, and Obesity in Youth Committee of the council on cardiovascular disease in the young and the council for high blood pressure research. Hypertension 2008;52:433‑51. 3. Lurbe E, Cifkova R, Cruickshank JK, Dillon MJ, Ferreira I, Invitti C, et al. Management of high blood pressure in children and adolescents: Recommendations of the European Society of Hypertension. J Hypertens 2009;27:1719‑42. 4. Furusawa ÉA, Filho UD, Junior DM, Koch VH. Home and ambulatory blood pressure to identify white coat and masked hypertension in the pediatric patient. Am J Hypertens 2011;24:893‑7. 5. Swartz SJ, Srivaths PR, Croix B, Feig DI. Cost‑effectiveness of ambulatory blood pressure monitoring in the initial evaluation of hypertension in children. Pediatrics 2008;122:1177‑81.
We compared the clinical and laboratory features of patients of peritonitis due to NTM and those of PD patients with bacterial peritonitis reported during these two years. We could not compare with peritonitis due to M. tuberculosis, for there were only three such patients during this period. The data are reported in Table 1.
Access this article online Quick Response Code:
disease (ESRD) patients were initiated on peritoneal dialysis (PD) at our institute. During this 14‑year period, there were 276 bacterial, 16 tuberculous, 68 fungal, nine nontuberculous mycobacterium (NTM), and 141 culture‑negative peritonitis episodes. The cumulative follow‑up of 650 patients was 13,710 months. We diagnosed nine cases as peritonitis due to NTM. Hence, the incidence of bacterial, tuberculous, NTM, and fungal peritonitis was one episode per 49.6, 856.8, 1523.3, and 201.6 patient–months, respectively. The patients of peritonitis presented in two clusters–in 2005 and 2012. The mean age was 51.11 years. There were eight males. All patients had growth identified as Runyon class IV: Rapid growers. There was growth on Löwenstein–Jensen medium between 4 and 11 days. The organisms were differentiated from Mycobacterium tuberculosis by BACTEC NAP test.[1]
Website: www.indianjnephrol.org DOI: 10.4103/0971-4065.120349
Only fever was found to be significantly associated with peritonitis due to NTM peritonitis when compared to bacterial peritonitis. An index of suspicion for NTM peritonitis would be an episode of peritonitis appearing early after placement of the catheter. Only one previous study [2] identified fever to be present in a higher percentage of patients of NTM peritonitis than in other peritonitis.
Peritonitis due to nontuberculous mycobacterium Sir, Between 1998 and June 2012, 650 end‑stage renal
During the same months of NTM peritonitis, there were reports of infection due to NTM in other surgeries performed at our institute. Culture of tap water and scrapings from the walls of operating room did not yield any growth. However, rapidly growing mycobacteria can be recovered from soil and natural water supplies, and are the most common NTM associated with nosocomial
Table 1: Patients of NTM peritonitis Patient
Age/sex
Cause of end stage renal disease
1 2 3 4 5 6 7 8 9
45/male 46/ male 46/male 65/female 45/male 60/male 48/male 55/male 50/male
CGN HTN CGN DM CGN CGN Renal calculus disease Obstructive nephropathy HTN
Duration of CAPD (days) 40 15 45 26 41 43 20 19 20
Differential cell count of peritoneal fluid
Fever
Neutrophilia Neutrophilia Lymphocytosis Neutrophilia Neutrophilia Neutrophilia Lymphocytosis Lymphocytosis Neutrophilia
Present Present Absent Present Absent Present Present Present Present
Total leucocyte count (×109/L)
Growth on LJ medium (day)
17.0 14.5 19.0 22.0 7.8 25.0 8.0 8.0 5.0
Day 4 Day 11 Day 7 Day 7 Day 7 Day 5 Day 4 Day 6 Day 11
NTM: Nontuberculous mycobacterium, CGN: chronic glomerulonephritis, HTN: hypertension
464
November 2013 / Vol 23 / Issue 6
Indian Journal of Nephrology
Copyright of Indian Journal of Nephrology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
