Urinary tract infection in nephrotic children: A cross-sectional study

Sabyasachi Bakshi; Subhendu Samanta

doi:10.4103/jina.jina_5_20

ORIGINAL ARTICLE

Year : 2020 | Volume : 7 | Issue : 1 | Page : 12-16

Urinary tract infection in nephrotic children: A cross-sectional study

Sabyasachi Bakshi¹, Subhendu Samanta²
¹ Department of General Surgery, NRS Medical College and Hospital, Kolkata, India
² Department of Pediatric Medicine, IDBG Hospital, Kolkata, India

Date of Submission	14-May-2020
Date of Decision	02-Nov-2020
Date of Acceptance	16-Jan-2021
Date of Web Publication	24-Aug-2021

Correspondence Address:
Dr. Sabyasachi Bakshi
Kathghara Lane, Sonatuli PO+District- Hooghly PIN 712103, West Bengal
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jina.jina_5_20

Abstract

Background and Objectives: Nephrotic syndrome, characterized by the presence of heavy proteinuria, hypoalbuminemia, edema, and hyperlipidemia, is a common renal disorder in pediatric population. The aim of this study was to find out the prevalence of urinary tract infection (UTI) in nephrotic syndrome, bacterial etiologies, and antibiotic sensitivity pattern. Subjects and Methods: After matching the criteria, 82 cases were taken for this prospective, single-center, observational study. The diagnosis was confirmed by bacterial culture. This is an institution-based, cross-sectional, descriptive observational study. All newly diagnosed and relapse cases of nephrotic syndrome based on the inclusion exclusion criteria were included in the study. Respondent was either of the parents or caregiver of the study subjects. Analysis of all data was done by appropriate statistical software (SPSS-23). Results: Among 82 participants evaluated with nephrotic syndrome, 29.3% of participants had UTI, majority (66.7%) were asymptomatic, and 33.3% were symptomatic. Significant microscopic hematuria was found in 20.7% of study subjects and significant pyuria was found in 58.54%. Majority (33.3%) of UTIs were caused by Escherichia coli, followed by Klebsiella 25%, Proteus 16.7%, and Staphylococcus aureus 12.5%, and Citrobacter, Acinetobacter, and mixed growth were found in 4.2% each. The mean serum cholesterol of group with UTI was 422.13 ± 34.65 and group without UTI was 307.43 ± 26.13. The variation among the two groups was found to be statistically significant (P = 0.0001). Conclusions: The children with nephrotic syndrome are frequently predisposed to UTI, and in most cases, it is asymptomatic and often undiagnosed. Higher serum cholesterol level may predispose the nephrotic child for UTI.

Keywords: Hematuria, nephrotic syndrome, pyuria, urinary tract infection

How to cite this article:
Bakshi S, Samanta S. Urinary tract infection in nephrotic children: A cross-sectional study. J Integr Nephrol Androl 2020;7:12-6

How to cite this URL:
Bakshi S, Samanta S. Urinary tract infection in nephrotic children: A cross-sectional study. J Integr Nephrol Androl [serial online] 2020 [cited 2023 May 28];7:12-6. Available from: http://www.journal-ina.com/text.asp?2020/7/1/12/324504

Introduction

Nephrotic syndrome is characterized by the presence of heavy proteinuria, hypoalbuminemia, edema, and hyperlipidemia and is a common renal disorder in pediatric population.^[1] Clovin and Goldberg used the term “Nephrotic Syndrome” to describe patient with edema, proteinuria, and hyperlipidemia. Synthesized steroid hormones were used as a treatment of nephrotic syndrome since 1950.^[2],[3] Nephrotic syndrome is a common clinical condition in Asian children.^[4] The prevalence of minimal change nephrotic syndrome is also higher in Indian subcontinent.^[5] There is a racial variation in susceptibility with a reported in incidence in Asian children of 9–16/100,000,^[5],[6] in comparison to 2–7 children in the USA, 2–4 new cases/100,000 children in the UK.^[7],[8] The pathogenesis of nephrotic syndrome is still not identified. Abnormalities in the functions of the T lymphocytes, in particular the suppressor T cells and the generation of circulating factors capable of altering the permeability of glomerulus to proteins, seem to be involved in the pathogenesis of the nephrotic syndrome.^[9] These patients have an increased risk of developing bacterial infections due to defective cell-mediated immunity, immunosuppressive therapy, malnutrition, and urinary losses of immunoglobulins, properdin factor B, and complement factors.^[10] Specially in developing countries as our infection is that one of the most important complications in nephrotic syndrome. Infection may lead to poor response to steroid and frequently results in relapse in a child who has already attained remission.^[11],[12] Among all infections, urinary tract infection (UTI) is of special interest because most of the UTIs in nephrotic syndrome are asymptomatic.^[13] Besides, in general, younger the child, the signs and symptoms of UTI are less localizing.^[14] Hence, it is often undiagnosed and important cause of prolonged hospital stay having a propensity for long-term renal damage,^[11],[15] UTI if left untreated in a patient of nephrotic syndrome who has been started on steroid therapy will complicate the course of both the UTI and nephrotic syndrome.^[16] UTI in nephrotic syndrome is associated with significantly lower serum albumin and also with higher serum cholesterol levels.^[17] Hypercholesterolemia is thought to inhibit lymphocytic function and thus may have a direct role in the precipitation of infection. Assessment of magnitude of problem would add to the existing figures of UTI prevalence which varies from study to study. Delineation of bacterial spectrum will help in selecting the empirical antibiotic therapy in UTI till the results of culture are awaited. The objective of the present study is to find out the prevalence of UTI in nephrotic syndrome, bacterial etiologies, and antibiotic sensitivity pattern.

Subjects and Methods

This was an institution-based (single-center), cross-sectional, descriptive observational study conducted in the Pediatric Medicine Department of Bankura Sammilani Medical College and Hospital (BSMCH) during from the time period of February 2018 to July 2019 the period of February 2018 to July 2019. During the present study, a total of 412 patients (258 males and 152 females) with nephrotic syndrome attended/admitted the outpatient/inpatient department of pediatric medicine. All newly diagnosed and relapse cases of nephrotic syndrome based on the inclusion exclusion criteria were included in the study. Respondent was either of the parents or caregiver of the study subjects.

Inclusion criteria

All patients with the age group of between 2 and 12 years and attending the pediatric outpatient department or admitted in the pediatric inpatient department with the diagnosis of nephrotic syndrome were included in the study. Ethical approval and consent to participate were obtained from the Institutional Ethics Committee, BSMCH, Kolkata, West Bengal, India. Approval letter (Memo No. BSMC/aca/44 dated January 2, 2018) is available for review by the editor of the journal. Written informed consent for participation in the study was obtained.

Exclusion criteria

Children with gross urogenital anomalies
Nephrotic syndrome with atypical presentation: hypertension and gross hematuria
Nephrotic syndrome with features of complications other than UTI
History of taking antibiotic during the last 15 days before admission
Where patient's care giver was unwilling to give consent.

The collected data was entered into SPSS(Statistical Product and Service Solutions)software, 23^rd Edition by IBM Knowledge Center,Inc. USA, software by IBM Knowledge Center, and to describe the data, frequency tables, statistical indicators, and diagrams were used. To analyze the relationships between variables, related tests including the Chi-square test and t-test were used.

Results

A total of 82 patients were finally enlisted and evaluated. Thorough history taking, clinical examination, and laboratory investigations were done as per case record form with special emphasis on the detection of UTI in the enlisted nephrotic patients. Then, the data were compiled and analyzed.

Baseline characteristics are depicted in [Table 1].

Table 1: Distribution of participants by age group and gender (n=82)

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Analysis revealed that majority of patients (63; 76.83%) belonged to the age group of 2–7 years. The overall average age was estimated as 5.59 ± 1.89 (mean ± standard deviation [SD]) years. The median age was 5.05 years with a range of 8.4 years. Out of 49 male patients, 38 (77.6%) belonged to the age group of 2–7 years and 11 (22.4%) belonged to 7–12 years. Out of 33 female patients, 25 (75.8%) belonged to 2–7 years and 8 (24.2%) belonged to 7–12 years. Among 82 participants, there was a male predominance (59.76%; n = 49). Male:female was 1.49:1.

[Figure 1] shows the distribution of participants by their UTI status (n = 82) and distribution of participants with UTI by symptoms (n = 24). Among 82 participants with nephrotic syndrome, 29.3% (n = 24) had UTI. Among participants with UTI, majority (19%; n = 16) were asymptomatic and 10% (n = 8) were symptomatic.

Figure 1: Distribution of participants by their urinary tract infection status (n = 82) and distribution of participants with urinary tract infection by symptoms (n = 24)

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The bar diagram in [Figure 2] shows the distribution of pyuria and hematuria among participants (n = 82).

Figure 2: Distribution of study population according to hematuria and pyuria pl

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In the present study, among 82 participants of nephrotic syndrome, significant microscopic hematuria was found in 20.7% (n = 17) and significant pyuria was found in 58.54% (n = 48).

The pie diagram in [Figure 3] shows causative agents of UTI isolated in the present study (n = 24).

Majority (33.3%; n = 8) of UTIs were caused by Escherichia ^{More Details} coli, followed by Klebsiella 25% (n = 6), Proteus 16.7% (n = 4), and Staphylococcus aureus 12.5% (n = 3), and Citrobacter, Acinetobacter, and mixed growth were found in 4.2% (n = 1) each.

Figure 3: Pie diagram showing causative agents of urinary tract infection isolated in the present study (n = 24)

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Urine culture sensitivity pattern of the present study is shown in [Table 2]. The present study revealed that majority (33.3%; n = 8) of UTIs were caused by E. coli, followed by Klebsiella 25% (n = 6), Proteus 16.7% (n = 4), and S. aureus 12.5% (n = 3), and Citrobacter, Acinetobacter, and mixed growth were found in 4.2% (n = 1) each. It was found that amikacin (81%), ofloxacin (80%), cefixime (90%), meropenem (79.2%), nitrofurantoin (72.2%), and piperacillin + tazobactam (95.2%) were very much effective against most of the culture isolates. However, S. aureus was found to be susceptible to Amoxyclav (100%), meropenem (66.7%), and linezolid (66.7%). Minor isolates were also found to be susceptible to most of the antibiotics.

Table 2: Urine culture sensitivity pattern

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In the present study population, Group A comprised nephrotic syndrome with UTI, and Group B comprised nephrotic syndrome without UTI.

[Table 3] shows baseline parameters among two groups. The study revealed that the mean Hb% of Group A was 10.23 ± 0.75 and of Group B was 10.43 ± 0.75. However, the variation among the two groups was not found to be statistically significant (P = 0.28). Average erythrocyte sedimentation rate (ESR) of Group A was 44.80 ± 10.15 and of Group B was 40.33 ± 10.45. This difference was not statistically significant (P = 0.09). The mean TLC of Group A was 11,538.33 ± 1282.19 and of Group B was 11,074.83 ± 1575.59. The variation among the two groups was not found to be statistically significant (P = 0.11).

Table 3: Baseline parameters among two groups

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In the present study, the mean serum protein of Group A was found to be 4.26 ± 0.27 and of Group B was found to be 4.24 ± 0.29. However, the variation among the two groups was not found to be statistically significant (P = 0.87). The average serum albumin of Group A was 2.36 ± 0.16 and of Group B was 2.41±0.20. This difference was not statistically significant (P = 0.30). The mean serum cholesterol of Group A was 422.13 ± 34.65 and of Group B was 307.43 ± 26.13. The variation among the two groups was found to be statistically significant (P = 0.0001). The average serum urea of Group A was 17.13 ± 2.25 and of Group B was 16.75 ± 2.30. This difference was not statistically significant (P = 0.49). The mean serum creatinine of Group A was 0.69 ± 0.09 and of Group B was 0.68 ± 0.08. The variation among the two groups was found to be insignificant (P = 0.58).

[Table 4] shows the comparison of serum albumin and serum cholesterol values between two groups among different studies.

Table 4: Comparison of serum albumin and cholesterol values between two groups among different studies

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Discussion

The nephrotic syndrome is an immunocompromised state and hence host is susceptible to a variety of infections.^{[18],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22]} This could be due to decreased serum immunoglobulin, protein deficiency, decreased bactericidal activity of the leukocytes, immunosuppressive therapy, decreased perfusion of the spleen caused by hypovolemia, and loss of a complement factor 3 (properdin factor 3) in urine that opsonizes bacteria. The pressure exerted by edematous pyramids on the collecting system causes narrowing and functional obstruction to the flow of urine, further predisposing them to UTI. Of all the infections in children, UTIs is significant because it can lead to long-term renal damage. In the current study, majority of patient (63; 76.83%) belonged to the age group of 2–7 years. The overall average age was estimated as 5.59 ± 1.89 (mean ± SD) years. The median age was 5.05 years with a range of 8.4 years. In our study, regarding clinical profile of the patient, it was observed that in participants with UTI, majority (16; 66.7%) were asymptomatic and 8 (33.3%) were symptomatic. In the present study, microscopic examination of urine showed pyuria in 15 (62.5%) in nephrotic syndrome with UTI patients and in 33 (56.9%) in nephrotic syndrome without UTI (P > 0.05, not significant). Microscopic hematuria was found in 8 (33.3%) UTI patients and in 9 (15.5%) patients without UTI that was not statistically significant (P > 0.05). In the present study, attacks of the nephrotic syndrome (first episode or relapse) were not found to be significant between the UTI groups and non-UTI groups. In the present study, the age, gender, ethnicity, religion, serum albumin, total protein, hemoglobin, ESR, serum creatinine, and serum urea were not statistically significant between the UTI groups and non-UTI groups. The mean serum cholesterol of nephrotic syndrome with UTI group was 422.13 ± 34.65 (mean ± SD) and of nephrotic syndrome without UTI group was 307.43 ± 26.13 (mean ± SD). The variation among the two groups was found to be statistically significant (P = 0.0001). In the present study conducted over 82 nephrotic syndrome patients, UTI was found in 24 (29.30%) cases. The results of this study showed that the most common microorganisms involved in UTI were E. coli (33.3%; n = 8), followed by Klebsiella 25% (n = 6), Proteus 16.7% (n = 4), and S. aureus 12.5% (n = 3), and Citrobacter, Acinetobacter, and mixed growth were found in 4.2% (n = 1) each. It was found that amikacin (81%), ofloxacin (80%), cefixime (90%), meropenem (79.2%), nitrofurantoin (72.2%), and piperacillin + tazobactam (95.2%) were very much effective against most of the culture isolates. However, S. aureus was found to be susceptible to Amoxyclav (100%), meropenem (66.7%), and linezolid (66.7%). Minor isolates were also found to be susceptible to most of the antibiotics.

Conclusion

The children with nephrotic syndrome are frequently predisposed to UTI,which is often asymptomatic and undiagnosed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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